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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406214951
Report Date: 05/25/2021
Date Signed: 05/25/2021 11:17:10 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GUTIERREZ FCC AKA KIDZ CAREFACILITY NUMBER:
406214951
ADMINISTRATOR:MARTHA GUTIERREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 221-5534
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:14CENSUS: 11DATE:
05/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Martha GutierrezTIME COMPLETED:
11:15 AM
NARRATIVE
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On 05/25/2021, at 8:36 AM, Licensing Program Analyst (LPA) Melissa Stewart conducted an unannounced investigation regarding the above allegations. LPA conducted a Pre-screening with Martha Gutierrez, Licensee prior to the inspection. All responses indicated non COVID-19 exposure. This case management report is documented to reflect the following deficiencies found during the course of Complaint Investigation 17-CC-20210514130509.

LPA observed nine (9) children including three infants supervised by Licensee and Assistant (S1). At 8:37am, LPA Stewart observed 8 month old infant (C1) sleeping on C1s side with a blanket over torso, an inch below C1s mouth, in a porta crib. There was an additional crocheted blanket in the porta-crib. Licensee removed both blankets from the porta crib and C1 woke up. Licensee stated that she did not have a sleep log for C1 or an Individual Infant Sleeping Plan (LIC 9227). Second Assistant (S2) arrived at 8:59am. LPA reviewed C1s file and Staff files. Licensee has not completed the re-newal of Mandated Reported Training per AB 1207, S1 has no record of completion of Mandated Reporter Training and S2 completed the General Training, but not the Child Care Provider Training (AB1207). Two additional children arrived.

Deficiencies cited today in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee, Martha Gutierrez, whose signature on this form confirm receipt of these documents.

Upon receipt, provide copies of this licensing report to each parent/guardian of enrolled children and to parents/guardians of newly enrolled children during the next 12 months. Acknowledgement of Receipt LIC 9224 form shall be used for this purpose. LIC 9224 after completed shall be maintained in each child's file. (LIC 9224 was provided to Licensee). Notice of Site Visit to be posted for 30 days.

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GUTIERREZ FCC AKA KIDZ CARE
FACILITY NUMBER: 406214951
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2021
Section Cited

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102425 Infant Safe Sleep- (d) The provider shall place infants up to 12 month of age on their backs for sleeping.

This requirement is not met as evidenced by:
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Based on observation, Licensee did not ensure that C1 was returned to back while sleeping which poses an immediate risk to the health and/or safety of children in care.
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LPA provided a copy of LIC9227 and Safe Sleep Regulation. Licensee will submit, to LPA, via email or text, a photo of completed LIC9227 for C1 on or before 5/25/21.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GUTIERREZ FCC AKA KIDZ CARE
FACILITY NUMBER: 406214951
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2021
Section Cited

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102425 Infant Safe Sleep- (c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.
This requirement is not met as evidenced by:
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Based on file review, Licensee did not ensure that C1 had an Individual Infant Sleeping Plan (LIC 9227) on file which poses a potential risk to the health and/or safety of children in care.
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Type B
05/31/2021
Section Cited

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§1596.8662 (b) (1) ....a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility... shall complete renewal mandated reporter training every two years.
This requirement is not met as evidenced by
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Based on file review, Licensee did not ensure that all staff had completed the AB1207 Mandated Reported training for Child Care providers every two years which poses a potential risk to the health and/or safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2021
LIC809 (FAS) - (06/04)
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