<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417393
Report Date: 08/20/2025
Date Signed: 08/20/2025 09:21:27 PM

Document Has Been Signed on 08/20/2025 09:21 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
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GUTIERREZ-DUBOSE FAMILY CHILD CAREFACILITY NUMBER:
197417393
ADMINISTRATOR/
DIRECTOR:		GUTIERREZ-DUBOSEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 773-1344
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 11DATE:
08/20/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:42 PM
MET WITH:Ana Maria Guiterrez DuboseTIME VISIT/
INSPECTION COMPLETED:
02:50 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
On 08/20/2025 Program Analyst (LPA), Judy Laureano conducted an unannounced Annual 3 year Required Inspection at above mentioned facility. LPA was greeted by Licensee, Ana M. Gutierrez-Dubose. Present during today’s inspection was Licensee’s husband.

LPA toured the inside and outside of the home and observed 11 children present with two staff members providing care and supervision.

LPA confirmed via Guardian roster that all individuals present in the home have a clear criminal record clearance.

The hours of operations are Monday to Friday open 7:30 a.m. to 5:30 p.m. License confirmed home cares for children ages 6 months to 5 years old. Facility is licensed for a Large Family Child Care license with a max capacity of 12 children.

This is a single-story single family home with 3 bedrooms, 2 bathrooms, living room, kitchen, front yard, backyard, and detached garage. The childcare areas are living room, bedroom 1, bedroom 2, bathroom 1, and kitchen.

Licensee confirmed the following areas as OFF LIMITS: bedroom 3, bathroom 2, detached garage, and front yard. LPA reminded licensee that any area designated as OFF LIMITS needs to remain locked and/or closed while children are present in the day care.

Upon entry, LPA entered the living room area, designated as day care. LPA observed age-appropriate materials such as toys and arts and craft materials. LPA observed children's size tables and chairs and a variety of children's books. Licensee confirmed that children nap in bedroom 1 and bedroom 2. Children eat in both the living room and kitchen area.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ-DUBOSE FAMILY CHILD CARE
FACILITY NUMBER: 197417393
VISIT DATE: 08/20/2025
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
26
27
28
29
30
31
32
Page 2
Parent board was observed in the living room area.

Bathroom that children use is located down the small hallway. LPA observed and inspected the toilet, sink and bathroom area. LPA reminded licensee to ensure all toiletries are made inaccessible to the children in care and/or while children are present.

The licensee was informed that any changes to ages, hours and days of operation shall be submitted to the department via signed LIC 279, for approval prior to initiation of changes.

Kitchen was observed and inspected. Knives and sharp objects were observed inaccessible to the children in care. Under the sink cabinet was observed and inspected. Licensee confirmed that cleaning solutions and detergents are kept under the sink cabinet and/or top cabinet; inaccessible to the children in care.

LPA observed a barricaded open face heater in the hallway and a barricaded fire place in the living room. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection.

Licensee confirmed that home is open to take in children that need incidental medical services. LPA discussed incidental medical services with Licensee. Prescription medications shall be administered in accordance with the label directions as prescribed by the child’s physician. Medication should be in its original content with current prescription with all necessary LIC forms completed.

LPA observed licensee test the smoke detector and carbon monoxide in the home. A working fire extinguisher was observed in the daycare space. LPA reminded licensee that fire extinguishers need to be service annually and proof of such service needs to be available for LPA’s review.

Licensee confirmed that fire drills and earthquake drills are completed at the home.

Home provides all meals and snacks. LPA discussed the importance of maintaining a system where allergies and food restrictions are noted. LPA encouraged licensee to contact their local resource and referral agency, Connections for Children, to inquire about the different resources and professional development opportunities available.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ-DUBOSE FAMILY CHILD CARE
FACILITY NUMBER: 197417393
VISIT DATE: 08/20/2025
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
26
27
28
29
30
31
32
Page 3
Adequate heating and ventilation for safety and comfort were observed in the space. The home has a working telephone service and LPA confirmed the phone number and email address.

Safe Sleep regulations were discussed due to program being available for infant care. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Infants up to 12 months of age are placed on their backs for sleeping. LPA discussed the importance of maintaining a current sleep log for all children under the age of 24 months. Licensee confirmed that children are always supervised when sleeping but a log has not been created. Type B citation was issued and License agrees to create a log that will be used for all children under the age of 24 months.

Capacity as specified on the license is being maintained during today’s inspection.

Licensee’s Pediatric CPR and Pediatric First Aid was taken by Licensee and assistants on 5/17/2025. Mandated Reporter Training was not available for review and a Type B citation was issued.

LPA discussed the importance of creating a file for licensee that includes all the necessary LIC documents, including but not limited to, First Aid and CPR, Mandated Reporter Training, Immunizations- MMR and tdap, TB clearance, and Flu Vaccine and/or waiver.

LPA reviewed 6 children’s file and observed files complete with all the necessary CCL forms.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC RO, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: GUTIERREZ-DUBOSE FAMILY CHILD CARE
FACILITY NUMBER: 197417393
VISIT DATE: 08/20/2025
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
26
27
28
29
30
31
32
Page 4
To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-proces.

Family Child Care Homes Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPAs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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 they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee, Ana M. Gutierrez-Dubose, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed and provided to Licensee Ana M. Gutierrez-Dubose.

NAME OF LICENSING PROGRAM MANAGER: Loyce Phillips
NAME OF LICENSING PROGRAM ANALYST: Judy Laureano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/20/2025 09:21 PM - It Cannot Be Edited


Created By: Judy Laureano On 08/20/2025 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GUTIERREZ-DUBOSE FAMILY CHILD CARE
FACILITY NUMBER: 197417393

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in not having a current sleep log for all children under 24 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2025
Plan of Correction
1
2
3
4
Licensee agrees to create and document the Safe Sleep check every 15 minutes. Sample log will be email to LPA by POC due date of 9/10/2025.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on recored review the licensee did not comply with the section cited above in not having Licensee and staff complete the Mandated Reporter training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2025
Plan of Correction
1
2
3
4
Licensee and staff will complete the Mandated Reporter Training by POC due date of 9/10/2025 and submit copy via email to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Loyce Phillips
NAME OF LICENSING PROGRAM MANAGER:
Judy Laureano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6