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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215801
Report Date: 07/20/2021
Date Signed: 07/20/2021 05:43:13 PM

Document Has Been Signed on 07/20/2021 05:43 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GUTIERREZ FAMILY CHILD CARE AKA KIDZ KLUBHOUSEFACILITY NUMBER:
406215801
ADMINISTRATOR:MICHAEL RICHARDO GUTIERREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 835-3741
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
07/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:07 PM
MET WITH:Michael GutierrezTIME COMPLETED:
04:24 PM
NARRATIVE
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On 7/20/21 at 4:07PM, Licensing Program Analysts (LPAs) Melissa Stewart and Martina Jimenez conducted an unannounced Case Management inspection in regard to complaint investigation # 17-CC-20210514132545 to document a deficiency cited. LPAs met with Licensee, Michael Gutierrez and the purpose of the inspection was explained. There were 10 children (including 3 infants) and one Assistant present when LPAs arrived at the facility.

During the course of the complaint investigation, LPA received documentation that Licensee, Martha Gutierrez (1713 Kleck Rd.), had been informed on 1/13/21 that child #1 (C1), enrolled at Michael Gutierrez' FCC, had tested positive for COVID19. On 1/16/21, Licensee Martha Gutierrez was informed that two (2) members of C1s family had also tested positive. On 1/23/21, Licensee Martha Gutierrez was informed that one member of the family had been hospitalized. This information was not reported by Licensee, Michael Gutierrez or Licensee Martha Gutierrez to Community Care Licensing Department (CCLD) as required.

Licensee, Michael Gutierrez denies this instance of receiving information regarding C1 testing positive for COVID19. Licensee acknowledged that C1s parent did disclose to Licensee, that both parents had tested positive. Licensee stated that he did not know that he was required to report the parents' positive test result to CCLD.

Deficiency cited today in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee, Michael Gutierrez, whose signature on this form confirm receipt of these documents.

LPA observed Licensee post Notice of Site Visit.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Melissa K Stewart
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
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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Document Has Been Signed on 07/20/2021 05:43 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Melissa K Stewart On 07/20/2021 at 04:19 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
, 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: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
07/20/2021
Section Cited
CCR
102416.2

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102416.2 Reporting Requirements
(b) The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.
This requirement is not met as evidenced by:
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Licensee stated that he now understands that all COVID19 positive cases or instances when a person is tested and is awaiting results whether they be children, parents, staff or others who have contact with the FCC must be reported to CCLD by phone call (805-562-0400) within 24 hours of receiving notice.
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Based on information received, Licensee, Michael Gutierrez was informed by C1s parent that C1s parents had both tested positive for COVID19. Licensee did not report these positive cases to CCLD per regulation noted above which poses a potential risk to the health and or safety of children in care.
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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
LICENSING EVALUATOR NAME:Melissa K Stewart
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2021


LIC809 (FAS) - (06/04)
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