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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415922
Report Date: 09/11/2023
Date Signed: 09/11/2023 05:15:18 PM

Document Has Been Signed on 09/11/2023 05:15 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, MARIAFACILITY NUMBER:
434415922
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
09/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Maria GutierrezTIME COMPLETED:
05:30 PM
NARRATIVE
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On 09/11/23 at Time 12:45 PM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee Maria Gutierrez, for an annual inspection. Present with licensee were adult daughter Dyana, with 1 preschool age child. Licensee was not home upon LPA arrival at 12:45 PM, licensee arrived 23 minutes later. Adults living in the home are licensee, her adult son and daughter and her 17 year old child. Days and hours of operation are Monday through Sunday, 06:00 AM to 06:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 08/16/2023 was reviewed and it indicates that not all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions, adult resident Maria has not obtained CACI clearance. Licensee Maria Gutierrez was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA inspected inside and outside of single-story home. Licensee owns the home and Licensee states she has liability insurance for a family childcare home (FCCH). LPA observed a 3A40BC fire extinguisher last purchased on 06/2023. Carbon Monoxide and smoke detectors are operable. LPA observed no wall heater, glass barricaded fireplace. Licensee stated there is no firearms/weapons in the home. Sharp objects, medicines, poisons, and cleaning supplies were accessible to the children, bathroom sink had a bottle of mouth wash, toothpaste and hair dye. Backyard is fenced. LPA observed no bodies of water and gated off limit right side yard area. Off limits indoor: master bedroom, two bedrooms, and the attached garage that has been converted for human habitation, licensee states she did not apply for construction permit. Off Limit outdoor: gated right side side of house with plastic storage shed.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 8 children according to her license. Licensee stated she does 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 09/11/2023 pg. 1/3


SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
Document Has Been Signed on 09/11/2023 05:15 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/11/2023 at 03:35 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, MARIA
FACILITY NUMBER: 434415922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in sink in bathroom used by children in care had mouthwash, toothpaste and hair dye, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2023
Plan of Correction
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Deficiency cleared during site visit, mouthwash, toothpaste and hair dye locked in off limit garage.
Type A
Section Cited
CCR
102416.3(a)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review,, the licensee did not comply with the section cited above in off limit garage has been converted for human habitation, bedroom, bathroom and kitchen, no city permit provided, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2023
Plan of Correction
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Licensee will submit a written plan to either obtain necessary city permits or restore Garage to its normal state to the San Jose Regional Office by close of business 09/12/23
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: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 09/11/2023 05:15 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/11/2023 at 03:35 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, MARIA
FACILITY NUMBER: 434415922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in adult resident Maria has obtained criminal background check without Child Abuse Central Clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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Licensee will submit proof of background check with CACI clearance by 09/26/23 to the San Jose Regional Office.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in child 1 (C1), C2, and C3 file's have CDPH 286 missing, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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Licensee will complete CDPH 286 for Child C1, c2 and C3 and mail copies to the San Jose Regional Office by close of business 09/26/23.
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: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 09/11/2023 05:15 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/11/2023 at 03:35 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, MARIA
FACILITY NUMBER: 434415922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Child 1 and Child 3 files is missing a Copy of emergency informaiton card, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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Licensee will sumbit a completed copy to the San Jose Regional Office by close of business 09/26/23.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Child C3 file is missing an emergency informaiton card, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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Licensee will sumbit a completed copy to the San Jose Regional Office by close of business 09/26/23.
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: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 09/11/2023 05:15 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/11/2023 at 03:35 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, MARIA
FACILITY NUMBER: 434415922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Facility Roster has not been updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2023
Plan of Correction
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Licensee will update the facility roster and submit a copy to the San Jose Regional Office by close of business 09/12/2023.
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: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 09/11/2023 05:15 PM - It Cannot Be Edited


Created By: Teodoro Trujillo On 09/11/2023 at 03:35 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, MARIA
FACILITY NUMBER: 434415922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Child C3 file has LIC 995A missing, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
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Licensee will submit a signed copy to the San Jose Regional Office by close of business 09/26/23.

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: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023


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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, MARIA
FACILITY NUMBER: 434415922
VISIT DATE: 09/11/2023
NARRATIVE
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Continuation of report dated 09/11/2023 pg. 2/3

LPA observed a current roster of the children had not been updated. LPA observed a fire and disaster drill log last performed on 4/21/2023. LPA reviewed 3 children’s files and observed not all required documentation was in compliance, LIC 627 missing for Child 1 (C1) and C3, C3 missing LIC 995A Parents Rights, LIC700 Emgercy Card. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was discussed. LPA observed licensee completed Mandated Reporter Training on 05/12/22. Licensee has Pediatric CPR/1st Aid expiring on 06/2025. 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 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 Maria Gutierrez and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee Maria Gutierrez 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 may 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 CARE tools, please send email inquiries 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/inspection-process.

Continues report dated 09/11/2023 pg. 2/3
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
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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, MARIA
FACILITY NUMBER: 434415922
VISIT DATE: 09/11/2023
NARRATIVE
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Continuation of report dated 09/11/2023 pg. 3/3
Licensee Maria Gutierrez was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the Licensee Maria Gutierrez confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the licensee Maria 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.

Type A and 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.

Type A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Maria Gutierrez that this report dated 9/11/2023 document(s) 2 (two) 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 Maria Gutierrez to provide a copy of this licensing report dated 09/11/2023 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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Teodoro Trujillo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
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