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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600647
Report Date: 09/26/2025
Date Signed: 09/26/2025 11:44:57 AM

Document Has Been Signed on 09/26/2025 11:44 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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:CAMPO KUMEYAAY HEAD STARTFACILITY NUMBER:
376600647
ADMINISTRATOR/
DIRECTOR:		VERLET MONTANOFACILITY TYPE:
850
ADDRESS:39639 OLD HIGHWAY 80TELEPHONE:
(619) 473-9022
CITY:BOULEVARDSTATE: CAZIP CODE:
91905
CAPACITY: 40TOTAL ENROLLED CHILDREN: 25CENSUS: 21DATE:
09/26/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Verlet MontanoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On September 26, 2025, at 9:10 a.m., Licensing Program Analyst (LPA), Angela Nguyen conducted an unannounced Required Inspection and met with Licensee Representative, Verlet Montano. LPA disclosed the purpose of the inspection and toured the indoors and outdoors of the facility. This is a full day program that operates following the yearly schedule of Mountain Empire Unified School District. The facility has two classrooms in operation. The following ratios were observed: Preschool Room 1 (serves 2-year-olds) with 4 children, two (2) teachers and one (1) assistant. Preschool Room 2 (serves ages 3-5 years old) was observed on the playground with 17 children, two (2) teachers and one (1) assistant present. Appropriate Title 5 staffing ratios are maintained during the inspection. Facility operates Monday through Friday from 8:00 a.m. to 4:00 p.m.

Furniture and equipment are in good condition. Floors in the facility are clean and safe. Toilets and hand-washing equipment are in safe and sanitary operating condition. Paper towels and toilet paper are available. The bathroom are lighted and has ventilation. Disinfectants, cleaning solutions and other hazardous items were made inaccessible to children during time of inspection. Kitchen, food preparation and storage areas are clean, free of litter/rubbish. Solid waste storage containers have tight fitting covers and are in good repair. Playground equipment is in safe condition. The surface of the outdoor activity space is maintained in a safe condition and free of hazards. Facility has smoke and carbon monoxide detectors that meet requirements. The last fire drill was conducted and documented on 9/26/2025. Earthquake drill was conducted and documented on 9/4/2025.
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Angela Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CAMPO KUMEYAAY HEAD START
FACILITY NUMBER: 376600647
VISIT DATE: 09/26/2025
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Licensee Representative stated that there are no swimming pools or other bodies of water on the premises. Licensee Representative stated that there are no firearms or ammunition allowed or stored on the premises.

The facility provides breakfast, lunch, and snack. Children bring their own water bottles and filter drinking water is available at the facility. Menus are posted monthly.

Licensee Representative stated that all employee’s working at this state preschool have received criminal record clearance with the Mountain Empire Unified School District.

Licensee Representative stated that all employees working at this preschool have obtained a health screening and TB as a condition of employment with the Mountain Empire Unified School District



Capacity and limitations as specified on the license are being maintained. Children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than eight (8) children in care. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility. The name of the facility representative and the fully qualified teacher designated to act in the facility representative’s absence has been reported to the Department. LPA reviewed facility sign in /sign out sheets. Facility utilizes a physical sign in/ out sheet. Licensee Representative was reminded that the person who signs the child in and out of the facility shall use their full legal signature and record the time of day. LPA reviewed a sample of children’s files and observed files to be complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. LPA reviewed a sample of staff files and determined they were complete.

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Angela Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: CAMPO KUMEYAAY HEAD START
FACILITY NUMBER: 376600647
VISIT DATE: 09/26/2025
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LPA and Licensee Representative discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, Resources, Mandated Reporter Training, California Megan’s Law (www.meganslaw.ca.gov), Lead Poisoning Facts, Forms and Regulations.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

No Deficiencies cited during this inspection.

A Notice of Site Visit (LIC 9213) was given to Licensee Representative, Verlet Montano and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. LPA observed LIC 9213 was posted. Appeal Rights (LIC 9058) was provided. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted and the report was reviewed with Licensee Representative, Verlet Montano.
NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Angela Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC809 (FAS) - (06/04)
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