Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313196
Report Date: 10/15/2019
Date Signed: 10/15/2019 05:34:46 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: 12DATE:
10/15/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Licensee Gutierrez Susan TIME COMPLETED:
05:55 PM
NARRATIVE
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Licensing Program Analyst (LPA),Ketki Desai conducted an unannounced annual/random inspection of the facility on today's date. LPA Ketki Desai toured the facility with the licensee Gutierrez Susan and a census taken. At the time of arrival LPA observed was licensee, with Twelve children ( 3 infants / 4 school age children and 4 Preschoolers with two assistants present providing additional support and care.

A review of staff criminal clearance records on this date indicates that all individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The LPA toured the facility inside and outside. All areas identified on the facility sketch were inspected. This is a single story home with 4 bedrooms, 2 bathrooms, kitchen, living / dining room/ Play room/ backyard/ Front yard and garage.

Family members residing at facility are Four adults and eight minors ( three children under age 10) and they are a part of Day care activities.

Areas inaccessible to children are Two bedrooms/ one bathroom/ kitchen and garage. The kitchen which was made inaccessible by a secured gated at the entrance to the kitchen located on the side of the dining room, the detached garage is on the side of the home and the door remains locked.

Areas accessible to children: Dining area/ 2 bedrooms used during napping time/ living room for recreational activities and a designated Play room. Parents access the Day care area through the main door through the front yard .


Operating hours are 6.00 am to 6.00 PM ( Monday to Friday)

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
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 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2019
Section Cited

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Immunizations: Employees or volunteers at family day care home; immunization requirements; records; The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section,
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in the person’s personnel record that is maintained by the family day care home.
This requirement is not met by evidence of record review of Licensee and 2 assistant missing the Immunization records. This poses a potential risk to H&S to children 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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: 10/15/2019
NARRATIVE
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The day care area was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medication, and hazardous items that can pose a danger to children.

Per licensee there are no weapons or firearms at the home. LPA did not observe any bodies of water in the facility. There are age appropriate toys and equipment for ages served. Facility remains clean and organized.

(Children use the bathroom next to the entrance door, observed to be clean)

Napping: Children nap in the two bedrooms, cots are available. Parents provide linens and blankets.

Licensee provides Breakfast/ Lunch / AM and PM Snacks and is associated to Food Program ( Family Resources)



The children are using the backyard and front yard of the home as the outside play area. .The backyard is fenced, and free of hazards. Backyard is open with shaded patio, age appropriate outdoor toys observed. Front yard has a shaded area and activities are done under adult supervision.

The required fire extinguisher (2A10BC), smoke detector, and carbon monoxide detector were in operable condition.

Licensee provides transportation services to the children, mainly picks up from school.

Licensee and the assistants need to be current on First Aid / CPR training ( Expired 9-23-19) and also need to complete the required Mandated Child Abuse training. Training web site: www.mandatedreporterca.com (AB1207)

Six children’s records were reviewed, including, Notification of parents’ rights, Parent notification additional children in care, Identification and Emergency information, Consent for emergency medical treatment, Affidavit regarding liability insurance for family child care home. Additional files for assistant and Licensee were also reviewed at the time of inspection.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 10/15/2019
NARRATIVE
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Licensee does not provide Incident Medical Services.

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.

The following was discussed with licensee: Providers guide to Safe Sleep, Never Shake a Baby, Ratio and Capacity, Quarterly updates, Advocate program contact, 25 E-learning Modules, Mandated Reporter training, Criminal record clearance, Unusual Incident Report (LIC624B), AB 2084 (Nutritious Beverages), Immunization for staff, Indoor/Outdoor activity space equipment condition, California Child Passenger Safety Law, Supervision. No smoking on premises, infant walkers, bouncers, Johnny jumpers, exersaucer or any other similar items that fall into that category are allowed in the facility.

Deficiencies cited per title 22 regulations on today's inspection.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 01/16) . All appeals must be in writing and received by the Licensing office within 15 business days.

Any proposed changes to the physical plant, including telephone number, shall be immediately reported to the Department.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2019
Section Cited

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Personnel Requirements: The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
The above requirement is not met by
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record review of Licensee and 2 assistants having an expired CPR/ FIrst aid training ( Expired: 9-23-19)
This poses a potential risk to H&S to children in care
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Type B
11/15/2019
Section Cited

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Mandated Reporting : On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, of a licensed child day care facility shall complete the mandated reporter training.
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This requirement is not met as evidenced by the file review conducted by LPA for Licensee and two Assistants and did not observe the certificate showing proof of completion of the training. This poses a potential risk to the health and safety of children 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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Ketki DesaiTELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5