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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408250
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:40:28 PM


Document Has Been Signed on 06/15/2023 02:40 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, 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:132CENSUS: 105DATE:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Gail and Alan PavloskyTIME COMPLETED:
12:45 PM
NARRATIVE
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On June 15, 2023 at 9:16am, Licensing Program Analyst (LPA) Indira Loza conducted an Unannounced Annual Required Inspection. LPA met with Director Gail Pavlosky, also present at the time of the inspection were 105 children and 12 fingerprint cleared staff. The facility is within ratio & capacity compliance today. The facility was toured to conduct a Health and Safety inspection. The facility currently operates between 7:45am through 5:30pm, Monday - Friday.

Classrooms: All classrooms were inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged 3A40BC fire extinguisher easily accessible throughout the facility.

Food Service: The children bring their own lunch and snacks from home.

Bathrooms: Facility has separate staff and child designated bathrooms. Toilets and faucets are in safe and sanitary operating condition. The children are able to reach the sinks and toilets. Supplies are available.

Outdoor Play Area: There are no bodies of water, or free-standing water accessible to children. There are age appropriate toys and materials for the children. The playground is fenced with all equipment and surfaces kept safe from hazards. The Toddler and Preschool classes have separate play yards.

Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 6 children’s files and 6 staff files. LPA reviewed the facility roster & personnel report. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. The center is in compliance with sign in and out procedure. All required documents are posted in a publicly accessible area.

*****************************************Report Continues on LIC809-C*************************

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GOOD EARTH SCHOOL, THE
FACILITY NUMBER: 073408250
VISIT DATE: 06/15/2023
NARRATIVE
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Director was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Personnel Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Director was reminded that California Law requires all facilities to report unusual incidents or injuries to children in care - to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone or fax. LPA informed Director that all forms can be downloaded at www.ccld.ca.gov. Director was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

This facility provides Incidental Medical Services – IMS. For IMS information see PIN 22-02. 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.

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

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 **********************************Report Continues on LIC809-C*************************
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 06/15/2023 02:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 073408250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239.2(a)
Drinking Water
(a) Drinking water from a noncontaminating fixture or container shall be readily available both indoors and in the outdoor activity area.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one faucet tested for lead had a lead exceedance level which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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The Licensee shall replace the fixture and retest with an official test result report indicating a lead level less than 5 parts per billion (ppb).
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 5 out of 6 staff did not have a current Mandated Reporter certificate whiich poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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The Licensee shall email the LPA a copy of a current Mandated Report certificate for the individuals reported to the Licensee.
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: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 073408250
VISIT DATE: 06/15/2023
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of any recalls on their purchased equipment.

See 809-D for two Type B deficiencies.



A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with Director Gail Pavlosky.
Report and appeal rights provided.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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