Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313196
Report Date: 10/09/2017
Date Signed: 10/09/2017 12:47:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GUTIERREZ, SUSANFACILITY NUMBER:
304313196
ADMINISTRATOR:GUTIERREZ, SUSANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 719-3115
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:14CENSUS: 2DATE:
10/09/2017
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susan GutierrezTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Jacqueline Moore met with applicant, Susan Gutierrez who guided analyst on a tour of the home. The applicant was previously licensed in Los Angeles County license # 198016888. All areas identified on the facility sketch were inspected. This is a detached single story home with 4 bedrooms and 2 bathrooms. Family members residing at facility are 4 adults and 7 minors. Applicant's 6 children, 2 whom were under the age of 10 were present during inspection. A review of staff records on today's date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Failure to complete clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the licensee.
The home was inspected for safety, comfort, cleanness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Control of property was reviewed. There are age appropriate toys on the premises. The fireplace was barricaded. No bodies of water were observed. Per licensee there are no weapons or firearms in the facility. The required smoke detector, 2A10BC fire extinguisher, and carbon monoxide detector were in operable condition during inspection. Sick children will be located in a designated area of one of the bedroom area until parent's arrival. Required postings were observed by LPA. Applicant had completed the EMSA Pediatric CPR & First Aid which expired on 9/17, and applicant had retaken the CPR & First Aid class, however applicant did not have current card/certificate during today's inspection. Proof of 8 hour Preventive Health certificate was observed. All day-care activities will take place in the living room, the dining room, bathroom adjacent from the entrance, kitchen, two bedrooms in the first hallway, day care room, bedroom adjacent from day care room and enclosed fenced back yard. .

Off limit areas include: The master bedroom and bathroom next to the master bedroom, and detached garage. The enclosed fenced backyard will be used for outdoor play. LPA advised applicant that children must be 100% visually supervised when not in an enclosed or gated area.

Continued on Page 2

SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2017
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GUTIERREZ, SUSAN
FACILITY NUMBER: 304313196
VISIT DATE: 10/09/2017
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Applicant had the required immunization's on file of Pertussis, Measles, and Influenza during today's inspection.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm


Advocate Program childcareadvocatesprogram@dss.ca.gov was reviewed and discussed. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org.
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative.
English: https//www.cdph.ca.gov/programs/SIDS/Doucments/SIDSchildcaresafesleep.pdf. Quarterly updates were reviewed and discussed.

The following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to presence in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, No infant walkers, No Johnny jumpers, No bouncers, No exersaucer and any other item that falls into that category are permitted in the facility. Disaster drills, posting requirements, children records, mandated child abuse and injury/death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby (copy given), Child passenger safety law (copy given), and Centralized Complaint and Information Bureau (copy given).

SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GUTIERREZ, SUSAN
FACILITY NUMBER: 304313196
VISIT DATE: 10/09/2017
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LPA Explained the following sample forms packet:
Children Records: LIC: 700 Identification And Emergency Information, LIC 995E Caregiver Background Check Process, LIC 995A Notification of Parent’s Rights, LIC 627 Consent For Emergency Medical Treatment, LIC 282 Affidavit Regarding Liability Insurance, LIC 9150 Parent Notification, Additional Children in Care. Copies given to applicant.

Facility Records: PUB 394 Notification of Parents Rights, LIC 9040 Facility Roster, LIC 624A Death Report, LIC 6101A Emergency Disaster Plan, LIC 9148 Earthquake Preparedness Checklist, LIC 624B Unusual Incident/Injury Report, and Fire/ Disaster Drill (copy given).

Staff Records: LIC 508 Criminal Record Statement, LIC 9052 Employee Rights, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse, LIC 9163 Request for LIVESCAN, LIC 9188 Criminal Record Exemption Transfer Request, LIC 9182 Criminal Background Clearance Transfer Request. Required Immunization's, TB test.

LPA received copies of LIC 508. Copy of family child care home ratio for large family child care homes given to applicant.

Web address for downloading forms or regulations was provided as http://ccld.ca.gov/PG411.htm.

Fire Clearance was received and approved for requested capacity.

The home was not incompliance with Title 22 Regulations. The following corrections will need to be submitted to the licensing office within 30 days. LPA informed applicant that a final review of the file, will be done before the license is issued. The applicant will be notified if any corrections or additions still need to be completed.


* Current EMSA certified CPR & First Aid * Air conditioning in backyard unit accessible to children.

Report was reviewed and discussed. Exit interview conducted with applicant and appeal rights procedure explained.

SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2017
LIC809 (FAS) - (06/04)
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