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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370806487
Report Date: 05/15/2023
Date Signed: 05/15/2023 12:30:46 PM


Document Has Been Signed on 05/15/2023 12:30 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: 77DATE:
05/15/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Modena MosherTIME COMPLETED:
12:20 PM
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On May 15th, 2023 at 11:17 AM, Licensing Program Analyst (LPA) JoAnn Legaspi conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of lead detected in a facility water fixture. LPA met with Site Supervisor Belaynesh Hanke. The purpose of the inspection was explained, and facility was toured. Present in facility were seventy-seven (77) children with eighteen (18) staff.

LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, which requires the testing of water for lead in Child Care Centers (CCCs) with staff during the inspection. Per AB 2370, all CCCs that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

The Department obtained copies of the External Water Sampler Self-Certification Form (LIC9275), Child Care Center Sampling Checklist (LIC9276), and Facility Sketch (LIC999).

The Department received notification from the State Water Resources Control Board (SWRCB), Division of Drinking Water (DDW). The SWRCB report indicated the facility was inspected and samples were collected on 08/31/2022. The outlets/fixture reported with 5.5 ppb or greater lead exceedance levels is as follows:

A- Kitchen Sink.

Staff reported the sink was made off limits, replaced and retested. The outlet was retested on 05/10/2023 to have no lead concentration above the CDSS action level of 5 parts per billion (ppb).

Lead Teacher Modena Mosher stated all staff were made aware of the ALE in the kitchen sink and has not utilized the sink for drinking water or food preparation.

SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
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: 05/15/2023
NARRATIVE
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Lead Teacher Mosher said the kitchen sink was only used for to wash dishes because all food is brought into the preschool by the preschool's main kitchen, located off site. Staff further said children do not use the kitchen sink and are given alternative potable water, by using alternate outlets, specifically water coolers.

Grant funding is available for testing and remediation of lead to the Child Care Centers that qualify. To make a determination of eligibility, refer to PIN 21-04-CCP. For Lead Testing and Prevention Information, including additional resources please visit https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information.



LPA informed Lead Teacher Mosher that this report dated 05/15/2023 documents one (1) Type B citation on the attached 809-D.

LPA advised Lead Teacher Mosher that parents must be notified of the lead exceedances. Licensee shall post testing results, in a location consistent with the requirements of subsection (b) of section 1596.8595 of the Health & Safety Code, for parents and families to view at the facility within 24 hours of receiving the results from the Department.

Exit interview conducted and report was reviewed with Lead Teacher Mosher. A copy of this report, along with Appeal Rights (LIC9058), were provided. A notice of site visit was given and must remain posted for 30 days. LPA observed that the notice of site visit was posted during the inspection. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2023 12:30 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2023
Section Cited

101700.3

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CA. Lead Action Level at Child Care Centers – “ … Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.” This requirement is not met as evidenced by: On 08/31/22, Lic. did not maintain a lead value at or below the Action
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The facility made the ALE affected outlet out of service and posted appropriate signage. Staff said the sink was replaced. The fixture was retested by a certified water sampler and a follow-up water sample taken following the protocol outlined in Written Directives, Section 101705. Staff further


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Level for water lead testing resulting with values of 5.5 ppb or greater for the kitchen sink. Water testing results identified with Action Level Exceedance (ALE) as defined in WD section 101700.3. are not deemed safe to drink. Based on record review, the Lic. did not comply with the above directive; the kitchen sink tested with ALE. This poses as a potential Health and Safety risk to children in care.
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said children in care do not use the kitchen sink and are given alternative potable water, by using water coolers. Staff said parents will be notified of the lead exceedances via email and/or letter. The outlet was retested on 05/10/2023 to have no lead concentration above the appropriate level. This deficiency has been cleared.

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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: Tulam VuTELEPHONE: (619) 767-2212
LICENSING EVALUATOR NAME: JoAnn R LegaspiTELEPHONE: (619) 767-2239
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
LIC809 (FAS) - (06/04)
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