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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701424
Report Date: 05/13/2019
Date Signed: 05/13/2019 01:34:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:GOOD SHEPHERD CATHOLIC SCHOOLFACILITY NUMBER:
376701424
ADMINISTRATOR:DESIREE FAJOTAFACILITY TYPE:
830
ADDRESS:8180 GOLD COAST DRIVETELEPHONE:
(858) 490-8200
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:20CENSUS: 0DATE:
05/13/2019
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Desiree FajotaTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Yolanda Baez met with Desiree Fajota at the San Diego Child Care Regional Office to comply with Component II orientation requirements.

The remaining application documents were reviewed and received during this visit which included: LIC 200A, LIC 309, LIC 308, LIC 500, Job Descriptions for Infant teacher and aides as well as Toddler Teachers and aides, In - service training plan, LIC 999, LIC 403, the employee handbook (to be reviewed by LPA), the parents handbook (to be reviewed by LPA), LIC 501 for Ms. Fajota, LIC 503 for Ms. Fajota, verification of director qualifications for Ms. Fajota, LIC 508 and LIC 9108 for Ms. Fajota.

Outstanding documents or items needed to complete the application are:

  1. the fire clearance
  2. LIC 200A: Application needs to be updated and signed by Matthew Cordes
  3. verification of financial information (LIC 404)
  4. LIC 610, please add 2 temporary relocation sites
  5. Admission Agreement form
  6. List of furniture and play equipment
  7. Control of property, should be a deed/rental agreement
  8. LIC 401: Monthly Operating Statement
  9. CPR/FA for Ms. Fajota, Orientation certificate for Component III for Ms. Fajota, proof of immunity for Pertussis (Tdap) and Measles
  10. The following is required for Matthew Cordes: Proof of immunity for Pertussis, measles, and Influenza, LIC 9108 (both pages MUST be filled and signed), Mandated Reporter certificate, orientation certificates for Component I and Component III orientations, LIC 508 (both pages MUST be filled and signed)
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: Yolanda BaezTELEPHONE: (619) 767-2201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2019
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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