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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403868
Report Date: 03/20/2024
Date Signed: 03/20/2024 11:46:43 AM

Document Has Been Signed on 03/20/2024 11:46 AM - 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: 11DATE:
03/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ana GutierrezTIME COMPLETED:
12:00 PM
NARRATIVE
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On 3/20/24 Licensing Program Analyst (LPA) Teodoro Trujillo conducted an unannounced Case Management to deliver amended reports from 09/08/23 and 12/20/23 site visits. LPA met with licensee, Ana Gutierrez. Present were the licensee, helper Luz and 11 children: 3 (three) infants, 8 (eight) preschool age.

Based on file reviews from the 09/08/23 site visit, Child C1 was missing from the Facility Roster. Licensee updated the roster during the 09/08/23 site visit.


Type B Deficiency was cited today for the 09/08/23 site visit. 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 was conducted and report was reviewed with Ana Gutierrez.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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 03/20/2024 11:46 AM - It Cannot Be Edited


Created By: Teodoro Trujillo On 03/20/2024 at 10:59 AM
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: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2024
Section Cited
CCR
102417(g)(8)

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Operation of a Family Child Care Home
Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
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Licensee added Child 1 to facility Roster during the site visit on 09/08/23. Deficiency has been cleared.
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Based on observation, interview, and record review, the licensee did not have Child 1 in facility Roster during site visit on 09/08/23, which poses/posed a potential health, safety or personal rights risk to persons 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:Susy Cervantes
LICENSING EVALUATOR NAME:Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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