406215801-1-6-2022-17-CC-MJIZ-CAETJW-20220106134701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406215801
Report Date: 01/06/2022
Date Signed: 01/06/2022 01:47:17 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) 835-3741
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY:	14	CENSUS: 3	DATE:	01/06/2022
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Michael Gutierrez		TIME COMPLETED:	01:55 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	Due to COVID-19 pandemic, LPA asked the pre-screening questions prior to inspection. Licensee's responses indicate there was no COVID-19 exposure on site. Licensing Program Analyst (LPA) Martina Jimenez conducted a Comprehensive Required Visit and met with Lily Poskin, Assistant, who stated that she has been working/volunteering for about a month. LPA reviewed LIS, and Guardian, which revealed Lily Poskin, was associated to the FCCH license on December 28, 2021. The Licensee, Michael Gutierrez, arrived at 11:30am, during the inspection. LPA observed 3 children in the home at the time of the inspection. LPA and licensee together toured the inside and outside of the home. The day care areas are located in the living room, family room, dining room and kitchen. The 5 bedrooms 2 bathrooms are secured with a gate at the bottom of the stairs and locks on the doors making them off limits to children. The bathroom was found clean and free of toxins. The carbon monoxide and smoke detectors were tested at 12:00pm and were found operational at the time of the inspection. The fire extinguisher was serviced May 3, 2021. The knives, cleaning supplies and medications are stored out of children reach. The children's records were reviewed and were found complete with State forms signed by child's parent or representative. The children's roster was found complete and updated. Licensee is This Report Continues on LIC 809C and LIC 809D

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina Jimenez	TELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

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: 01/06/2022

NARRATIVE

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current with CPR and First Aid which expires May 27, 2023. Licensee is current with immunization requirements per SB 792. Licensee completed the Mandated Reporter training per AB 1207 on June 15, 2021. All required State forms were posted on the consumer board.

Licensee stated that there are no guns or ammunition in the home. No bodies of water were observed. Licensee stated she does not have a foster care license.

Licensee is not providing Incidental Medical Services. 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

LPA reviewed the handout "A Child Care Provider's Guide to Safe (PIN 20-24 CCP) Safe Sleep Plan, and Effects of Lead Exposure. LPA provided a Handout for Reporting Child Abuse and Neglect Training provided on line at www.ccld.ca.gov. Licensee was reminded that it is her responsibility to know the regulations for Family Child Care Home and was advised to review Quarterly Updates and Provider Information Notices (PINs), Title 22 & Health & Safety Codes which can be accessed on-line athttps://www.cdss.ca.gov/inforesources/child-care-licensing

Today, deficiency cited under Title 22 Division 12 Appeal rights given.

Upon receipt of this report, licensee shall post and provide copies of this licensing report to parents /guardian of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. Licensee to provide LIC 9224 for each child in care and have each parent sign the form that they have received a copy of the report LIC 809 and LIC 809 D. 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: Martina Jimenez	TELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

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: 01/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/07/2022 Section Cited	1 2 3 4 5 6 7	All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on (interview and record review)], the licensee did not comply with the section cited above, Staff 1, stated she has been working/volunteering for about a month. The criminal record clearance was on 12/28/2021, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Martina Jimenez	TELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

LIC809 (FAS) - (06/04)

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