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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403868
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:26:09 PM

Document Has Been Signed on 04/26/2023 12:26 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: 11DATE:
04/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Ana GutierrezTIME COMPLETED:
12:36 PM
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On 04/26/2023 at 11:50 PM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Ana Gutierrez for a case management Plan of Correction Visit (POC). Present were licensee, her spouse and assistant Luz with 11 children: two (2) infants and nine (9) preschool age. Previous to today's visit, LPA conducted an annul inspection on 04/25/2023 and did not provide licensee with LIC421BG Civil Penalty Assessment signed form.. LIC421BG and POC Letter of Deficiency Citations Cleared for the Type A deficiency was provided.

No deficiencies were cited during today's visit. Exit interview was conducted and report was reviewed in Spanish with Licensee, Ana Gutierrez Failure to comply with posting requirements shall result in an immediate civil penalty of $100. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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