434415243-4-11-2023-07-CC-EBEN-CQSJ9T-20230411065137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415243
Report Date: 04/04/2023
Date Signed: 04/11/2023 06:52:14 AM

Document Has Been Signed on 04/11/2023 06:52 AM - It Cannot Be Edited

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:	GUTIERREZ, DOLORES		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 910-7996
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	14	CENSUS: 9	DATE:	04/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Dolores Gutierrez		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Dolores Gutierrez for a required 1 year inspection. LPA observed 9 napping children and Licensee's adult daughter, Yanira Gutierrez. Dolores states her assistant, Laura Quiroz is out on lunch. Adults living in the home are Licensee, her husband (Jose Gutierrez), daughter (Yanira Gutierrez), and son (Adolfo Gutierrez). Licensee has a minor 13 year old son who lives in the home. Days and hours of operation are Monday to Friday 6:00 AM to 6:00 PM. LPA inspected the inside and outside of the home. The two story unit behind the garage has a separate entry from the side yard and is not being used. The two story unit is currently vacant. Off limits indoor: bedroom 1, bedroom 2, bathroom 1, kitchen, garage, and the two story unit behind the garage. No bodies of water were observed. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide detectors. Fire place in off limits area. Licensee states that there are no weapons or firearms in the home. LPA observed a current children's roster and copy was obtained during the inspection. Fire/disaster drill was conducted on March 20, 2023. Incidental Medical Services (IMS) policy was discussed. Licensee states that she is not planning to administer any medication at this time. 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 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 Continuation on next pages:

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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: 04/04/2023

NARRATIVE

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LPA reminded licensee that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 910-7996.

LPA reviewed 9 children’s files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), Immunization Records, Notification of Additional Children in Care (LIC 9150), and Acknowledgement of Receipt of Licensing Report (LIC 9224).

LPA reviewed a helper's file for the following records: Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), Employee Rights (LIC 9052), required immunization's, TB test, and Mandated Reporter Training. Licensee's Mandated Reporter Training expires on November 14, 2024. Yanira Gutierrez (assistant) mandated reporter training expired on 03/01/22. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years. Licensee has current Pediatric CPR/First Aid certification with an expiration date of February 11, 2025.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended she registers all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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: 04/04/2023

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

Exit interview conducted and report was reviewed with Licensee, Dolores Gutierrez

As a result of today's inspection, there were no deficiencies cited.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC809 (FAS) - (06/04)

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