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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417393
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:32:01 PM

Document Has Been Signed on 12/12/2022 03:32 PM - 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GUTIERREZ-DUBOSE FAMILY CHILD CAREFACILITY NUMBER:
197417393
ADMINISTRATOR:GUTIERREZ-DUBOSEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 773-1344
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ana Maria Gutierrez DuboseTIME COMPLETED:
02:00 PM
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On 12/12/2022, Licensing Program Analyst (LPA) Lillian Casillas attempted to conduct an unannounced Annual Required Inspection. LPA met with Licensee, Ana Maria Gutierrez-Dubose, and explained the purpose of the visit. Days and hours of operation are Monday through Friday, from 7:30am to 5:00pm. LPA observed 9 children and 1 assistant (cleared and associated to the facility).

During today's inspection, LPA conducted a tour of the inside and outside of the facility. This is a single-story single family home with 3 bedrooms, 2 bathrooms living room, kitchen, front yard, backyard, and detached garage. Childcare areas are living room, bedroom 1, bedroom 2, bathroom 1, and kitchen. Off limit areas are bedroom 3, bathroom 2, detached garage, and front yard. Upon entry, LPA entered the living room. LPA observed age appropriate toys, learning materials, children's tables and chairs, games and activities for children in care. All furniture was found in good repair, clean and without hazards. Children use the bathroom located in the hallway. Bedroom 1 is called the playroom and bedroom 2 is used for napping. Bathroom includes 1 toilet and 1 sink. The kitchen was observed to be clean and organized. LPA observed knives stored in an upper cabinet. Licensee stated facility provides water and meals/snacks as part of the Evergreen food program. Children eat on children's tables in the kitchen. LPA observed functioning smoke/carbon monoxide detectors in the living room, bedroom 1, and hallway. LPA observed the 2A10:BC fire extinguisher (serviced 2022) and first-aid kit in the kitchen.

Indoor Off-Limits: The bedrooms are made inaccessible by child safety knobs. Bathroom 2 can only be accessed via bedroom 3.



Inspection of the outdoor play area was conducted. Climbing structures, slides and other large play equipment are located on the grassy area of the fully enclosed, large backyard. There is adequate shade for the children in care. Playground is free from miscellaneous debris such as tree branches, trash, leaves, etc.

[CONTINUE ON PAGE 2]
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ-DUBOSE FAMILY CHILD CARE
FACILITY NUMBER: 197417393
VISIT DATE: 12/12/2022
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Outdoor Off-Limits: The detached garage is made inaccessible by a door lock. Licensee stated children do not utilize the front yard.

Facility currently provides care to 1 infant. LPA observed the child's 15 minute sleeping check log. LPA is complying with Safe Sleep regulations.

Facility was observed to be operating within the conditions, limitations, and capacity specified on the license. LPA reviewed Licensee's file to be complete: CPR and Pediatric First-Aid expires 10/2024 and Mandated Reporter training expires 8/10/2024. LPA reviewed a sample of 5 children’s files and observed files were complete.

Licensee was reminded that all adults 18 and over, 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 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. Upon notification from the Department, the licensee will comply and act immediately to terminate the employment of, remove from the facility or bar from entering the facility for any person it is deemed necessary while the Department considers granting or denying an exemption.

Incidental Medical Services (IMS) are currently being provided. Director is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

Exit interview conducted and a copy of this report was provided to Licensee, Ana Maria Gutierrez-Dubose, along with the Notice of Site Visit.

SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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