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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215801
Report Date: 03/21/2024
Date Signed: 03/21/2024 04:37:22 PM

Document Has Been Signed on 03/21/2024 04:37 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GUTIERREZ FAMILY CHILD CARE AKA KIDZ KLUBHOUSEFACILITY NUMBER:
406215801
ADMINISTRATOR:MICHAEL RICHARDO GUTIERREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 835-3741
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 9DATE:
03/21/2024
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Michael Richard GutierrezTIME COMPLETED:
04:50 PM
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On March 21, 2024, at 11:15 AM, Licensing Program Analyst (LPA) Martina Jimenez conducted a Comprehensive Required Annual inspection of the Gutierrez Family Child Care Home (FCCH). LPA met with Michael Richard Gutierrez, Licensees and minor assistant. The purpose of the inspection was explained, and LPA and Licensee together toured the interior and exterior of the FCCH. LPA observed two (2) infants and seven (7) children in care at the time of the inspection.

The area used for child care are as followed; living room, hallway bathroom, and backyard. LPA observed in the downstairs bedroom#1, to be unsecured at the time of the inspection. LPA observed in the downstairs bedroom antiacid chew, calcium, perfume, RMFLEX, centrum vitamins, lotion, ect.. accessible to children in care. The children's bathroom was observed to be clean and free of toxins. LPA observed the day care area to be clean and orderly. LPA observed age appropriate books, toy, games, tables and chairs.

LPA observed the off-limits areas to be the second floor, which includes four (4) bedrooms, and two (2) bathrooms, downstairs off limits areas are one (1) bedroom unsecured at the time of the inspection, one (1) bathroom unsecured at the time of the inspection, family room, kitchen and garage. LPA observed a safety gate a the bottom
CONTINUES ON LIC809C & LIC809D
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE AKA KIDZ KLUBHOUSE
FACILITY NUMBER: 406215801
VISIT DATE: 03/21/2024
NARRATIVE
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of the stairs making the second floor inaccessible to children in care. LPA observed a safety gate at the entrance to the kitchen and family room making the kitchen, family room and garage inaccessible at the time of the inspection.

LPA and licensee together toured the outdoor play area. The play area has age-appropriate toys and day-care equipment. LPA and licensee discussed active supervision when children are in the outdoor yard. There were no bodies of water observed at the time of the inspection. Licensee stated there are no bodies of water at the home. LPA advised the licensee children must never be unsupervised while the children are at the play area.

Licensee stated that there are no weapons/ammunition in the home. Licensee stated he does not hold a foster family license. The fire extinguisher was observed and was serviced May 9, 2023. Licensee is reminded to service or purchase the fire extinguisher yearly. There is a functioning carbon monoxide detector and smoke alarm that were tested at 11:39 am, in the home, that meets statutory requirements. First Aid and emergency kits are available.

Licensee and assistant are current with immunization required per SB 792. The last Safety drill was conducted and documented was on December 21, 2023. Licensee is current with CPR and First Aid which expires May 16, 2025. Mandated Reporter Training is valid until June 28, 2025. Facility roster and a sample of children's records were reviewed at 2:01 PM and found C6's file is missing LIC627.

CONTINUES ON LIC 809-C & LIC 809D
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
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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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE AKA KIDZ KLUBHOUSE
FACILITY NUMBER: 406215801
VISIT DATE: 03/21/2024
NARRATIVE
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LPA observed posted facility license (LIS203), and parents rights (PUB394) in a prominent location adjacent of the front interior door. The emergency disaster was not available at the time of the inspection.

The licensee provided proof of control of property. The licensee has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the licensee understands that, once licensed, they can operate with a maximum capacity of 12 children. If property owner/landlord consent is obtained in the future, the licensee is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 14 children.



There are three (3) adults living in the home, which all adults residing in the home have been fingerprint cleared. Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Continues on LIC809C & LIC809D
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE AKA KIDZ KLUBHOUSE
FACILITY NUMBER: 406215801
VISIT DATE: 03/21/2024
NARRATIVE
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ยท All adults living and working in the home shall be made of aware of the Department inspection rights authority.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

LPA also informed licensee 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee 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.

CONTINUES ON LIC809C & LIC809D
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
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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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GUTIERREZ FAMILY CHILD CARE AKA KIDZ KLUBHOUSE
FACILITY NUMBER: 406215801
VISIT DATE: 03/21/2024
NARRATIVE
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During the exit interview, the Licensee, Michael Richard Gutierrez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Michael Richard Gutierrez.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 04:37 PM - It Cannot Be Edited


Created By: Martina Jimenez On 03/21/2024 at 03:32 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GUTIERREZ FAMILY CHILD CARE AKA KIDZ KLUBHOUSE
FACILITY NUMBER: 406215801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

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, the licensee did not comply with the section cited above by LPA observed in the downstairs bedroom#1, to be unsecured at the time of the inspection. LPA observed in the downstairs bedroom antiacid chew, calcium, perfume, RMFLEX, centrum vitamins, lotion, ect.. accessible to children in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Licensee will submit photos of correction and a written statement on how licensee will prevent future incidents from occurring to CCLD by 3/22/2024, via email to; [email protected]
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:Maria Mueller
LICENSING EVALUATOR NAME:Martina Jimenez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


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Document Has Been Signed on 03/21/2024 04:37 PM - It Cannot Be Edited


Created By: Martina Jimenez On 03/21/2024 at 03:32 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
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: GUTIERREZ FAMILY CHILD CARE AKA KIDZ KLUBHOUSE
FACILITY NUMBER: 406215801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above at the time of the inspection LPA observed facility license (LIS203), and parents rights (PUB394) in a prominent location adjacent of the front interior door. The emergency disaster was not available at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee agrees to email CCLD a copy of the completed and posted emergency disaster plan by 3/28/2024, via email: [email protected]
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 LPAs observation and record review, the licensee did not comply with the section cited above in ensuring all children's file have a completed LIC627. LPAs review of children's records review found C6's file was missing LIC627, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee agrees to email CCLD a copy of the completed LIC627 for C6 by 3/28/2024, via email: [email protected]
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:Maria Mueller
LICENSING EVALUATOR NAME:Martina Jimenez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


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