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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701294
Report Date: 06/06/2024
Date Signed: 06/06/2024 12:41:11 PM

Document Has Been Signed on 06/06/2024 12:41 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:ST. JOHN'S HEAD STARTFACILITY NUMBER:
376701294
ADMINISTRATOR/
DIRECTOR:		NEISY IBANEZFACILITY TYPE:
850
ADDRESS:760 FIRST AVENUETELEPHONE:
(619) 869-8983
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 270TOTAL ENROLLED CHILDREN: 270CENSUS: 120DATE:
06/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Neisy IbanezTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 6/6/2024, at 9:30 a.m., Licensing Program Analyst (LPA) Adrian Castellon conducted an unannounced Case Management inspection to follow upon on the Unusual Incident reported to the Department on 5/21/2024. Upon arrival, LPA met with Site Supervisor, Neisy Ibanez, and discussed the purpose of the inspection. LPA was led on a tour of the facility.

On 5/6/24 at approximately 10:00am, child in care suffered what looks like a rug burn while in care at the facility. LPA requested video footage.

Staff reported incident to child representative verbally on date incident occurred and via incident report the following day.

LPA conducted staff interviews on this date. LPA obtained an incident report and took a picture of playground equipment.

Based on information gathered at this time, further investigation is needed.

Exit interview conducted and report was reviewed with the facility representative, Neisy Ibanez. Appeal Rights, and Notice of Site Visit were given. Notice of Site Visit is required to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. LPA observed Notice of Site Visit posted.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Adrian Castellon
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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