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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495108
Report Date: 04/07/2023
Date Signed: 04/07/2023 02:45:05 PM

Document Has Been Signed on 04/07/2023 02:45 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GOOD SHEPHERD'S FOLD PRESCHOOLFACILITY NUMBER:
197495108
ADMINISTRATOR:ZURBRUGG, PHIL E.FACILITY TYPE:
850
ADDRESS:1350 W. 25TH STREETTELEPHONE:
(310) 833-3340
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY: 60TOTAL ENROLLED CHILDREN: 42CENSUS: 24DATE:
04/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Maria Valin, Director TIME COMPLETED:
02:55 PM
NARRATIVE
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On 04/07/2023, Licensing Program Analyst (LPA) Denise Miranda conducted a Case Management- Deficiencies visit for the purpose of citing for the deficiencies that were observed during the visit on 04/07/2023.

LPA met Maria Valin, Director. There were 24 children in care being supervised by 3 staff and one volunteer.

Based on observation, and record review and interviews, facility was not able to produce proof of immunization for volunteer and staff#3.



Per Title 22, Division 12, Chapter 6, of the California Code of Regulations, the following deficiencies is being cited: (see next page, 809 D)

An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit was provided to Maria Valin, Director.



SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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Document Has Been Signed on 04/07/2023 02:45 PM - It Cannot Be Edited


Created By: Denise Miranda On 04/07/2023 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: GOOD SHEPHERD'S FOLD PRESCHOOL
FACILITY NUMBER: 197495108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
HSC
1596.7995

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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
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Director agreed to submit proof of immunization for volunteer#1 and staff#3. Director will email proof of the following immuzation: MMR, Dtpa, TB (no older than
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Based on record review, the licensee did not comply with the section cited above in 1 volunteer present and Staff# 3 did not have proof of immunization, which poses/posed a potential health, safety or personal rights risk to the childl in care.
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one year) and flu vaccination. Flu vacination, faciltiy can provide copy of waiver or proof of immunization. Director agreed to submit via email to LPA no later than 04/21/2023.

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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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