406215801-7-3-2019-17-CC-SMCA-BDQRQ7-20190703131305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406215801
Report Date: 07/03/2019
Date Signed: 07/03/2019 01:13:24 PM

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 FAMILY CHILD CARE AKA KIDZ KLUBHOUSE		FACILITY NUMBER:	406215801
ADMINISTRATOR:	MICHAEL RICHARDO GUTIERREZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(805) 221-5534
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	14	CENSUS: 0	DATE:	07/03/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Michael Gutierrez		TIME COMPLETED:	01:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A prelicensing visit was conducted by Licensing Program Analysts (LPAs) S. Mendoza-Ceja and G. Reyes who met with Michael Gutierrez. The entire home was toured inside and outside. Mr. Gutierrez stated the children will have access to the downstairs area which includes the primary day care room/living room which is secured with gates, the restroom, and backyard. Mr. Gutierrez stated children will be escorted through the dinning area/kitchen to the backyard for outside play time. LPAs observed a gate making the upstairs inaccessible to day care children. Mr. Gutierrez stated the off limits areas include the upstairs bedrooms (securely gated), the downstairs bedroom which were observed to have a chain latch, including the laundry room which leads to the garage, and kitchen/dining area and second living room making the areas inaccessible to children. Mr. Gutierrez was advised if any chain latches or gates become ineffective, it is his responsibility to make the areas inaccessible to day care children. Mr. Gutierrez stated there are no firearms, ammunition or bodies of water on the premises. LPAs did not observe any bodies of water. There is a 2 A10 BC Fire Extinguisher in the home which was serviced 05/21/2019. Mr. Gutierrez was advised the Fire Extinguisher needs to be serviced or replaced yearly. The carbon monoxide detector and smoke detector were tested. LPA also advised of the requirement to conduct fire drills and disaster drills at least once every six months. Mr. Gutierrez was also advised to document the drills, including the date and time of each drill. This documentation shall be maintained. The record keeping requirements including the handouts "A Child Care Provider's Guide for Safe Sleep, Safe to Sleep in Child Care, and the Effects of Lead Exposure" were reviewed. Mr. Gutierrez has completed the 16 Hours of Health and Safety. Mr. Gutierrez's CPR and First Aid is current (expires 03/20/2021).

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Sylvia Mendoza-Ceja	TELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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 FAMILY CHILD CARE AKA KIDZ KLUBHOUSE	FACILITY NUMBER: 406215801
	VISIT DATE: 07/03/2019

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LPA reviewed SB 792 the requirement for care providers/employees, including volunteers to obtain immunization against Influenza, Pertussis, and Measles. Verification of immunizations was reviewed for Mr. Gutierrez. LPA advised each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. LPA also reviewed the requirement to complete the AB1207 Child Mandated Reporter Training for all employees. Mr. Gutierrez has completed AB1207 Child Mandated Reporter Training.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Prior to licensure the following must be completed:
1. Submit verification of MMR and Tdap for assistant
2. Submit verification upon completion of the AB1207 Child Abuse Mandated Reporter
Training for assistant.
3. Submit verification of Statement of Acknowledgement of Child Abuse (LIC9109)
Michael Gutierrez and assistant.
4. Submit verification the air conditioning unit and bbq are inaccessible.
5. Fire Inspection Clearance for the Large FCCH.
The Notice of Site Visit was posted.
FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Sylvia Mendoza-Ceja	TELEPHONE: (805) 722-5132
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

LIC809 (FAS) - (06/04)

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