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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370806487
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:36:28 PM


Document Has Been Signed on 05/04/2023 12:36 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, 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: 85DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Modena MosherTIME COMPLETED:
12:30 PM
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On May 4th, 2023 at 10:00 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a case management inspection to follow-up on an incident that occurred on 04/17/2023. LPA advised Site Supervisor Belaynesh Hanke of the inspection’s purpose and was granted facility entry. Lead Teacher Modena Mosher provided LPA with a facility tour.

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


There were five (5) children with two (2) staff members.

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

Classroom #2 (serves children aged 3 – 5 years):
There were sixteen (16) children with two (2) staff members.

Classroom #3 (serves children aged 3 to 5 years):
There were fifteen (15) children with two (2) staff members.

Classroom #4 (serves children aged 3 to 5 years):
There were fifteen (15) children with two (2) staff members.

Classroom #5 (serves children aged 3 to 5 years):
There were seventeen (17) children with three (3) staff members.

Classroom #6 (serves children aged 3 to 5 years):
There were twelve (12) children with three (3) staff members.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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: 05/04/2023
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On 04/17/2023, two (2) classrooms were outside on the playground; there were a total of twenty-four (24) children with six (6) staff members. Child 1 (C1) ran in the playground but tripped on their feet. (See LIC 811 Confidential Names). C1 fell forward and struck their chin on a cement curb in the playground. This caused a laceration to C1’s bottom chin. Staff notified C1’s mother, who brought their child to the hospital for medical treatment.

During this inspection, LPA inspected the playground and observed the incident site. LPA also interviewed Staff 1 and Staff 2. LPA also attempted to interview C1, but they declined the interview. 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 Mosher. Licensee/Appeal Rights (LIC 9098) along with a copy of this report was provided to Lead Teacher Modena 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: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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