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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215801
Report Date: 07/20/2021
Date Signed: 07/20/2021 05:44:38 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: 10DATE:
07/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Michael GutierrezTIME COMPLETED:
05:58 PM
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Due to COVID-19 pandemic, LPA Jimenez asked the pre-screening questions prior to inspection. Licensee's responses indicate there was no COVID-19 exposure on site.

On 7/20/2021, at 4:25 PM, Licensing Program Analysts (LPAs) Martina Jimenez and Melissa Stewart, conducted an unannounced Required Annual Inspection of the Gutierrez Family Child Care Home. LPAs met with Michael Gutierrez, Licensee, and Sara Guerrero, Assistant. The purpose of the visit was discussed with the Licensee and together we toured the inside and outside of the home. LPA observed 7 children and 3 infant in care at the time of the inspection.

The main day care areas are living room/day-care room, and bathroom. LPAs observed the day care area to be clean and orderly. LPAs observed age appropriate books, toy, games, tables and chairs. LPAs observed the off-limits areas which include the kitchen, family room, 5 bedrooms and 3 bathrooms, and 2nd story of the home. LPAs observed the off limit areas secured with locks and gates. The backyard is completely fenced. LPAs observed age appropriate toys, bikes, play structure and playhouses. LPA observed 2 small outdoor dog.

No bodies of water were observed. Licensee stated that there are no weapons/ammunition in the home. Licensee stated he does not hold a foster family license. Sampling of children's records were reviewed. The fire extinguisher was observed and was serviced May 3, 2021.

THIS REPORT CONTINUES ON LIC 809C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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
VISIT DATE: 07/20/2021
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There is a functioning carbon monoxide detector and smoke alarm that meets statutory requirements, were tested at 3:58pm and were functioning at the time of the visit. Licensee is current with immunization required per SB 792. The last Safety drill was conducted February 22, 2021. Licensee is current with CPR and First Aid which expires May 21, 2023.

Licensee is not providing Incidental Medical Services. Incidental Medical Services (IMS) policy was discussed. 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: htttp://www.ada.gov/childqanda.htm

Licensee completed the Mandated Reporter Training on June 15, 2021, that is required per AB 1207. LPA reviewed the handout "A Child Care Provider's Guide to Safe Sleep" (PIN 20-24) and Effects of Lead Exposure. LPA provided a Handout for Reporting Child Abuse and Neglect Training provided online at www.ccld.ca.gov.



There were no deficiencies cites at this time. LPA observed licensee post the Notice of Site visit FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC809 (FAS) - (06/04)
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