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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153801077
Report Date: 09/07/2021
Date Signed: 09/07/2021 04:28:16 PM

Document Has Been Signed on 09/07/2021 04:28 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:GOOD SHEPHERD PRESCHOOL & CHILD CARE CENTERFACILITY NUMBER:
153801077
ADMINISTRATOR:ARNECKE, KRISTENFACILITY TYPE:
850
ADDRESS:329 S. MILL ST.TELEPHONE:
(661) 823-7740
CITY:TEHACHAPISTATE: CAZIP CODE:
93561
CAPACITY: 64TOTAL ENROLLED CHILDREN: 0CENSUS: 21DATE:
09/07/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Kristen ArneneckeTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Ortega, met with Director, Kristen Arnecke for a Case management deficiencies inspection. During the inspection the following was observed:

Personal Rights: COVID-19 facial (mask) were not observed on children and adults(Staff) and (Parents) during the inspection.

Facility was cited Type B deficiency, according to California Code of Regulations Title 22. LIC809D issued for deficiency. An exit interview was conducted, a copy of this report was read and provided to Director Kristen Arnecke.
SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/07/2021 04:28 PM - It Cannot Be Edited


Created By: Isabel Ortega On 09/07/2021 at 03:31 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: GOOD SHEPHERD PRESCHOOL & CHILD CARE CENTER
FACILITY NUMBER: 153801077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2021
Section Cited
CCR
101223(a)(2)

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Personal Rights: Each child shall be accorded safe, healthy and comfortable accommodations, furnishing and equipment. This was not met as evidence by: LPA observed no children nor Staff and no adult visitors wearing facial coverings in accordance to CA Public Health and Safety guidelines. This is a potential health and safety risk for children in care.
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Director will submit a written statement to CCL by 9/8/2021 how facility will ensure all children, staff and adults entering the facility over the age of 2 years shall wear facial covering while indoor setting and how all adults entering the facility will abide by the same policy. Director will also attend a scheduled Local Licensing Call held by CCL on 9/27/2021.
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All children including Staff and adult visitors (parents, children who enter the facility) over the age of 2 years are required to wear facial covering while indoor setting except (napping and eating) to help mitigate the spread and transmission of Covid-19 and accordance to CA Public Health and safety Guidelines.
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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:Carissa Bell
LICENSING EVALUATOR NAME:Isabel Ortega
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2021


LIC809 (FAS) - (06/04)
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