434415243-6-20-2019-07-CC-JTSE-BDBT6Z-20190620142757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415243
Report Date: 06/20/2019
Date Signed: 06/20/2019 02:28:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	GUTIERREZ, DOLORES		FACILITY NUMBER:	434415243
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 3	DATE:	06/20/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Dolores Gutierrez		TIME COMPLETED:	02:40 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	LPA Janet Tse met with licensee Dolores Gutierrez for an annual/random inspection. Licensee is also applying for an increase of capacity to a Large Family Child Care Home license. LPA observed three children with Licensee. Present was also Licensee's 10-year-old child. Adults living in the home are Licensee, her husband, her adult son, her adult daughter, a nephew and a niece of Licensee's husband (who live in the two story unit behind the garage), with a 10-year-old child. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. LPA toured the inside and outside of the home. The two story unit behind the garage has a separate entry from the side yard. Off limits indoor: bedroom 1, bedroom 2, bathroom 1, kitchen, garage, and the two story unit behind the garage. There are no bodies of water. Licensee stated there is no firearms/weapons in the home. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Backyard is fenced. LPA observed a built in barbeque grill and a locked storage shed in the backyard. Three dogs were in the fenced dog run in the left side yard. Licensee stated that the dogs are vaccinated. Off limits outdoor: the dog run, and fenced off area next to the storage shed. Fire extinguisher was size 3A40BC and filled. Smoke and carbon monoxide detector was operable. Home was clean and orderly with heating and ventilation for safety and comfort. LPA observed sufficient materials, toys, and play equipment for the day care children. Telephone was in working order. Children were supervised on the visit and LPA went over substitute options. LPA also discussed if licensee transports children, they are never to be left in parked vehicles. A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 06/17/2019 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. Facility Evaluation Report dated 06/20/2019 to be continued on next page:

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2019

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GUTIERREZ, DOLORES	FACILITY NUMBER: 434415243
	VISIT DATE: 06/20/2019

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Facility Evaluation Report dated 06/20/2019 to be continued from previous page:

LPA obtained a copy of the roster of the children and reviewed three children's files. LPA observed that in each child’s record has a copy of the emergency information card that contains all of the information specified by regulation. LPA observed that Licensee has completed training on preventive health practices, and has current Pediatric CPR/1^st Aid expiring 01/06/2020. Licensee was given a list of the current forms for childcare. LPA discussed the immediate civil penalties for Zero Tolerance of $500, and an ongoing $100 per day per violation continues until the violation(s) is corrected. LPA also discussed the Healthy Beverage Act and AB633 requirements for type A violation. LPA observed the required immunization records per SB792 for Licensee are in file. Incidental Medical Services were discussed with the licensee. Licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care. Information on Safe Sleep Practice and Lead Poisoning was also provided to Licensee.

No deficiency was cited. Notice of site visit was issued and must be posted for 30 days. Licensure for a Large Family Child Care Home License is approved and effective today, 06/20/2019.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2019

LIC809 (FAS) - (06/04)

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