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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440709682
Report Date: 09/18/2019
Date Signed: 09/18/2019 10:55:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GOOD SHEPHERD SCHOOLFACILITY NUMBER:
440709682
ADMINISTRATOR:KRISTEN BARKMANFACILITY TYPE:
850
ADDRESS:2727 MATTISON LANETELEPHONE:
(831) 476-4000
CITY:SANTA CRUZSTATE: CAZIP CODE:
95065
CAPACITY:30CENSUS: 22DATE:
09/18/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Kristen BarkmanTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA), Behbood, conducted an unannounced random visit to the Facility today. LPA met with Kristen Barkman, Site Supervisor. Purpose of the visit explained. LPA toured inside and outside of the facility during today's visit.
LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus (includes current and following week), and Activity Schedule.
All staff have criminal record clearances on LIS. Ratio was met. No bodies of water observed. LPA reviewed samples of children's file and sign in and out sheets during today's visit. Each child's file reviewed contains the Information and Emergency Information form (LIC 700) and a copy of the admission agreement. LPA observed that all children were properly signed in and out (legal signature & time of day) by a parent or authorized representative. All staff have current CPR and First Aid certifications and proof of immunization on file . Staff files have copies of their educational background. Furniture & equipment appear in good condition. Floors appear clean. Kristen stated one toilet bowl in PS class broke this morning and will be fix by tomorrow as the custodian is off today. Present in that class today is 8 children. The other 3 toilets bowl is operational.
Facility provides snacks only, children bring lunch from home. Preschool refrigerator appears clean & all food is covered. Children bring their own water bottle from home. Trash can for food waste has a tight fitting cover. Menu is posted.
Playground has climbing structures, etc. Wood chips and sands are used for cushioning material. Incidental Medical Services were discussed with the licensee. This facility provides Incidental Medical Services (IMS). Currently none of the children require this service,
Effect of lead exposure poster was provided to licensee and for their information and to share with children. Discussed also was safe sleep. No citation issued during today's visit.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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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