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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403868
Report Date: 12/20/2023
Date Signed: 12/20/2023 01:26:50 PM

Document Has Been Signed on 12/20/2023 01:26 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
SAN JOSE CC RO, 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: DATE:
12/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Ana GutierrezTIME COMPLETED:
12:38 PM
NARRATIVE
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Licensing Program Analyst(LPA) Teodoro Trujillo met with Ana Gutierrez, Licensee, for an unannounced case management visit. Present with licensee and assistant Luz were ten (10) children: seven (7) preschool age, and three(3) infants. Licensee spouse and minor child arrived during visit.

The following issues were discussed during today's visit: Based on self-report and file review, Licensee has failed to continue to document the 15 minute sleep logs for Infant child 1(C1) and C2. Copy of CCR 102425 was provided to licensee Ana.

Type B Deficiencies were cited today. 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 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: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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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Document Has Been Signed on 12/20/2023 01:26 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 12/20/2023 at 12:56 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: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2024
Section Cited
HSC
1102425(j)(2)(D)(c)

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The provider shall supervise infants while they are sleeping and adhere to the following requirements:
(1) The provider shall physically check on the infant every 15 minutes.
(2) .. and document the following:
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

a. Date.
b. Infant’s name.
c. Time of each 15-minute check.
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Licensee will submit copies of 15 minute safe sleep check for C1 and C2. Licensee will also submit a written statement of her understanding
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Based on interview and record review, the licensee did not comply with the section cited above in child 1(C1) and C2 did not have 15 minute sleep check, which poses/posed a potential health, safety or personal rights risk to persons in care.
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of CCR 102425 Infant Sleep to the San Jose Regional Office by close of business 01/04/23.

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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:Susy Cervantes
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
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