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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102819
Report Date: 09/10/2019
Date Signed: 09/10/2019 01:38:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOOD SHEPHERD LUTHERAN SCHOOLFACILITY NUMBER:
210102819
ADMINISTRATOR:JESSICA MCINTYREFACILITY TYPE:
850
ADDRESS:1180 LYNWOOD DRIVETELEPHONE:
(415) 897-2510
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:122CENSUS: 32DATE:
09/10/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jessica MclntyreTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Farhan Bashir-Tariq performed an unscheduled Case Management inspection at the facility above. LPA met with Director Jessica McIntyre. The purpose of the inspection was explained, which was to inspect the new layout of the playground installed for the preschool program. Present there were 32 children in care with 9 staff.

LPA observed that the playground was free from hazards, free from sharp, loose, or pointed parts. The fall zones are surrounded with tan bark to act as cushioning to absorb falls. Facility installed a sand box into the outdoor space, which is blocked off from children and not in use at this point. Sand box will be used after installing the covers and sand.

Director states that the preschool program has exclusive use of the playground space. A schedule of the preschool and updated sketch will be provided to the Department. Gates have been installed on both sides of the playground connected to the main school building. Playground is fenced off all around.

>No deficiencies were cited today under Title 22 Division 12 of the California Code of Regulations.


Facility was advised for any additional questions to call Office, M-F, 8AM-5PM at 650-266-8800 . For Rules and Regulations, visit the Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2019
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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