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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418559
Report Date: 12/08/2021
Date Signed: 12/08/2021 04:03:52 PM

Document Has Been Signed on 12/08/2021 04:03 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:VOLUNTEERS OF AMERICA, MONA HOUSE HEAD STARTFACILITY NUMBER:
197418559
ADMINISTRATOR:LOPEZ, M AND WROTEN, MFACILITY TYPE:
850
ADDRESS:13124 MONA BOULEVARDTELEPHONE:
(310) 933-0728
CITY:COMPTONSTATE: CAZIP CODE:
90222
CAPACITY: 56TOTAL ENROLLED CHILDREN: 41CENSUS: 23DATE:
12/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Battine Brav, Site SupervisorTIME COMPLETED:
04:15 PM
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 Licensing Program Analyst (LPA) Tiffanie Tran arrived at the above facility to conduct a Case Management Incident inspection that was self-reported on 11/03/21 regarding an enrolled child suddenly loss of consciousness and fainted during outside time.

LPA completed child's record review and obtained child's document and personnel report. Based on the interview conducted with staff, child, and other, it indicates on the day of the incident there were 13 children with three staff. Staff observed the incident and immediately provided health and safety protocol to assist the child. Paramedic was dialed and parent was contacted in a timely manner. At this time based on the available information it does not appear this incident was the result of a Title 22 violation for Personal Rights.

No deficiency was found during today's inspection.

The content of this report was read and discussed in detail at the time of with the noted contact person.

An exit interview was conducted; the notice of site visit must be posted for 30 days upon receipt.
SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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