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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600390
Report Date: 10/12/2021
Date Signed: 10/12/2021 03:47:18 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:GOOD SHEPHERD PRE SCHOOLFACILITY NUMBER:
300600390
ADMINISTRATOR:ALVAREZ-MACKOW, BERNADETTEFACILITY TYPE:
850
ADDRESS:7082 CRESCENT AVENUETELEPHONE:
(714) 827-6440
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:74CENSUS: 12DATE:
10/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Bernadette Alvarez-Mackow, DirectorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) P Rivas conducted a case management visit and reviewed five staff files.

A review of the Facility Personnel Report Summary and staff files on this date 10/12/2021 at 09:00 AM indicated all facility staff present or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The following deficiency is cited under the California Code of Regulations Title 22 Division 12 (see lic 809d)

An exit Interview was conducted. Report was reviewed and discussed. The director was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. The Notice of Site Visit was posted. Director 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. LPA informed the licensee of how to access regulations and forms from CCLD websites: www.cdss.ca.gov
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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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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: GOOD SHEPHERD PRE SCHOOL
FACILITY NUMBER: 300600390
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2021
Section Cited

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1596.8662(4)(b)(1)On or before March 30, 2018, a person who, ..licensed child care provider, administrator, ... mandated reporter training provided pursuant to paragraphs (2) and (3) of ... 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:
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as evidenced by LPA review of 5 of 5 staff files; No current certificate in any file was observed and director statement that their certificates have expired. This poses a potential hazard 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021
LIC809 (FAS) - (06/04)
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