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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403868
Report Date: 04/25/2023
Date Signed: 04/25/2023 05:32:00 PM

Document Has Been Signed on 04/25/2023 05:32 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GUTIERREZ, ANAFACILITY NUMBER:
434403868
ADMINISTRATOR:GUTIERREZ, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 363-9648
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Ana GutierrezTIME COMPLETED:
05:45 PM
NARRATIVE
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On 04/25/2023 at 1:37 PM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Ana Gutierrez, for an annual inspection and explained the reason for the visit to her. Present during today's visit were licensee, her spouse and assistant Luz with 9 children: one (1) infant and 8 preschool age. Adults living in the home are licensee and, her spouse and 13 year old minor child. Days and hours of operation are Monday through Friday 07:30 AM to 5:30 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 4/10/2023 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have not received criminal record and child abuse index clearances or exemptions, assistant Luz has not been associated to licensee child care home as of 08/24/2022. Licensee was reminded 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 inspected inside and outside of home. LPA observed a glass covered fireplace, no wall heater, no stairs, and no bodies of water. LPA observed a patio playroom leading to the backyard from the home. Licensee stated there are no weapons. Licensee stated she has one dog. LPA observed a 3A40BC fire extinguisher last serviced 08/04/2021. A combination Carbon Monoxide/smoke detector is operable. Sharp objects, medicines, poisons, and cleaning supplies were inaccessible to the children in care. Off limit areas inside the home: all three bedrooms and one bathroom, and the garage. On limit areas: family room, hallway bathroom, and kitchen area. On limit areas outside the home: left and rear back yard. Off limit outside: gated right yard corner, storage shed and right side yard area.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to her license. Licensee stated she does not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.



Continues report dated 04/25/2023 pg. 1/3
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, ANA
FACILITY NUMBER: 434403868
VISIT DATE: 04/25/2023
NARRATIVE
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Continuation of report dated 04/25/2023 pg. 2/3
LPA observed a roster of the children. LPA observed a fire and disaster drill log last performed on 03/24/2023. LPA reviewed 5 children’s files and observed Child 1 (1) and C2 are missing Infant 15-minute check sleep log, and C1 is missing LIC9227 Individul Infant Sleeping Plan. LPA observed licensee completed Mandated Reporter Training on 07/21/22, assistants Luz completed 11/03/2021. Licensee has Pediatric CPR/1st Aid that expiring on 11/14/2024, assistant Luz expires 09/18/2023. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is current for licensee, and all adults helping or residing in the home.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS currently. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA 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-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 they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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.

Continues report dated 04/25/2023 pg. 2/3

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
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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, ANA
FACILITY NUMBER: 434403868
VISIT DATE: 04/25/2023
NARRATIVE
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Continuation of report dated 04/25/2023 pg. 3/3
Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Ana Gutierrez that this report dated 04/25/2023 document(s) 1 (one) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPA Teodoro Trujillo informed the licensee Ana Gutierrez to provide a copy of this licensing report dated 04/25/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.
Exit interview conducted and report was reviewed in Spanish with the licensee, Ana Gutierrez. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
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Document Has Been Signed on 04/25/2023 05:32 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 04/25/2023 at 04:33 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GUTIERREZ, ANA
FACILITY NUMBER: 434403868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(2)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Assistant Luz has been working at licensee child care home since August 2022 without being associated to the child care facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2023
Plan of Correction
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LIcensee will send Criminal Background Transfer Request LIC 9162 with copy of ID/Driver license to the San Jose Regional Office by close of business 04/26/2023, assistant will not be present until Luz is assocated to facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mary Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


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Document Has Been Signed on 04/25/2023 05:32 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 04/25/2023 at 04:33 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GUTIERREZ, ANA
FACILITY NUMBER: 434403868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in fire extinguisher last serviced 08/04/2021, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2023
Plan of Correction
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Deficiency cleared during site visit, spouse had fire extinguisher serviced.
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Child 1 was asleep on top of loose blanket during site visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2023
Plan of Correction
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Deficiency cleared during site visit, loose blanket removed from infant crib.
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:Mary Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2023 05:32 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 04/25/2023 at 04:33 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GUTIERREZ, ANA
FACILITY NUMBER: 434403868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Child 1 and Child 2 have 15-minute check missing from childrens file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Licensee will submit copies of 15-minute sleep check for Child 1 and Child 2 to the San Jose Regional Office by close of business 05/05/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mary Segura
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


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