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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215801
Report Date: 05/21/2021
Date Signed: 05/21/2021 01:47:01 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 KLUBHOUSEFACILITY NUMBER:
406215801
ADMINISTRATOR:MICHAEL RICHARDO GUTIERREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 835-3741
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:14CENSUS: 8DATE:
05/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Michael GutierrezTIME COMPLETED:
01:50 PM
NARRATIVE
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On 5/21/21 at 8:55am, Licensing Program Analyst (LPA) Melissa Stewart conducted an unannounced inspection in regard to a complaint (allegations listed above). LPA met with Licensee, Michael Gutierrez, who was wearing a face covering and explained the nature and the purpose of the inspection. Licensee took LPAs temperature and explained the COVID19 protocol for children as they arrive. Licensee provided LPA with a tour of the home inside and outside. There were 8 children (including one infant) present along with two adult Assistants. There is a child safety gate at the foot of the stairs. The upstairs bedrooms and bathrooms are off-limits to children in care. Licensee's adult relative was upstairs in one of the bedrooms. Licensee reported that his relative had arrived for a two week visit and did not live in the home, nor was the relative providing care to children. This case management report reflects the following deficiencies found during the course of Complaint Investigation #17-CC-20210514132545.

Based on review of the files of 15 currently enrolled children, nine (9) did not have a record of immunization and two (2) did not have the ID and Emergency Contact (LIC700) on file. Deficiencies cited today in accordance with the California Code of Regulations, Title 22, see LIC809D.

LPA left the facility at 10:09am to complete the reports and returned at 1:15pm. 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, Michael Gutierrez, whose signature on this form confirm receipt of these documents. LPA provided Licensee, Michael Gutierrez with a Notice of Site Visit (LIC 9213) to be posted for 30 days. Failure to post LIC9213 as required may result in a $100.00 civil penalty.

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

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2021
Section Cited

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102417 Operation of a Family Child Care Home (7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency....
This requirement is not met as evidenced by:

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Based on file review, C5 and C6 did not have a ID & Emergency Information (LIC700) on file which poses a potential risk to the health and safety of children in care.
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Type B
05/28/2021
Section Cited

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102418 Immunizations (a)Prior to admission to a family day care home, children shall be immunized....(g)The licensee shall document each child's immunizations as required... for as long as the child is enrolled. (1)This requirement includes updating each child's PM 286...
This requirement is not met as evidenced by:
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Based on file review, nine (9) out of 15 children's files did not have any record of immunizations nor the PM286 (blue card). Licensee failed to ensure that proof of immunizations were on file for review by LPA which poses a potential risk to the health and 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: 05/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2021
LIC809 (FAS) - (06/04)
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