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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370806487
Report Date: 03/24/2023
Date Signed: 03/28/2023 07:16:39 AM


Document Has Been Signed on 03/28/2023 07:16 AM - 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108



FACILITY NAME:NHA HOME AVENUE HEAD START FAMILY FOCUS CENTERFACILITY NUMBER:
370806487
ADMINISTRATOR:MINDY LINDOMULLIGANFACILITY TYPE:
850
ADDRESS:4111 HOME AVENUETELEPHONE:
(619) 262-8199
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY:120CENSUS: 5DATE:
03/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Lead Teacher Modena Chappell-MosherTIME COMPLETED:
02:40 PM
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On March 27th, 2023, at 1:45 PM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a case management inspection to follow-up on an incident that occurred on 03/13/2023. LPA advised Office Assistant Yanitza Patino of the meeting’s purpose and was granted facility entry. Lead Teacher Modena Chappell-Mosher provided LPA with a facility tour.

Classroom #1A (serves children aged 18 months to 3 years):


There were four (4) children with two (2) teachers.

Classroom #1B (serves children aged 18 months to 3 years):
There were five (5) children present with two (2) teachers.

Classroom #2 (serves children aged 3 – 5 years):
This classroom was empty.

Classroom #3 (serves children aged 3 to 5 years):
This classroom was empty.

Classroom #4 (serves children aged 3 to 5 years):
This classroom was empty.

Classroom #5 (serves children aged 3 to 5 years):
This classroom was empty.

Classroom #6 (serves children aged 3 to 5 years):
This classroom was empty.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: NHA HOME AVENUE HEAD START FAMILY FOCUS CENTER
FACILITY NUMBER: 370806487
VISIT DATE: 03/24/2023
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On 03/13/2023, about three (3) to four (4) children were playing outside on the playground, with one (1) teacher and one (1) substitute teacher. The facility used to have cut out shapes on the playground area. On 03/13/2023, these cut out shapes were on the playground ground, while a child jumped from shape to shape. The child slipped and landed face forward onto the ground. Staff comforted the child, attended to their bleeding mouth, and contacted the parent. The child sustained a bruised gum and about 1 inch cut on their bottom lip. The parent brought the child to an hospital emergency room. Medical staff directed the parent to allow the child rest and allow the wounds to naturally heal- no medical care was administered. The child’s parent has no concerns or complaints about the facility. Staff removed the cut out shapes from the center.

During this inspection, LPA inspected the playground and observed no cut out shapes in this area. The incident appears accidental, the facility took prompt action by administering first aid and notifying the parent. No deficiencies cited.

Staff was provided with A Notice of Site Visit (LIC 9213), which is to be posted for thirty (30) days. An exit interview was conducted with Lead Teacher Chappell-Mosher Licensee/Appeal Rights (LIC 9098 03/22) along with a copy of this report was provided to Lead Teacher Modena Chappell-Mosher and their signature on this form confirms receipt of these rights.

SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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