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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408250
Report Date: 11/17/2021
Date Signed: 11/17/2021 02:57:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:GOOD EARTH SCHOOL, THEFACILITY NUMBER:
073408250
ADMINISTRATOR:GAIL PAVLOSKYFACILITY TYPE:
850
ADDRESS:1 LAWSON ROADTELEPHONE:
(909) 816-8919
CITY:KENSINGTONSTATE: CAZIP CODE:
94707
CAPACITY:120CENSUS: 100DATE:
11/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alan PavloskyTIME COMPLETED:
03:00 PM
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On 11/17/21 at 2:00 PM Licensing Program Analyst (LPA) Michelle Sutton conducted an unannounced Case Management inspection about an unusual incident self reported by the Center about a child running away from the mother after pick-up. LPA met with administrator Alan Pavlosky and director Gail Pavlosky and explained the purpose of today's inspection.

LPA interviewed the administrator and director. LPA also observed the yard and where parents have pick-up. Copies of The Children's Roster, Personnel Report and relevant documents were obtained during today's inspection.

There are no deficiencies being cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the administrator Alan Pavlosky and director Gail Pavlosky.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle SuttonTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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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