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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343610212
Report Date: 12/17/2019
Date Signed: 12/17/2019 01:52:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CHAMPIONS @ ROY HERBURGER ELEMENTARYFACILITY NUMBER:
343610212
ADMINISTRATOR:TOTAH, MANUELAFACILITY TYPE:
840
ADDRESS:8670 MARANELLO DR.TELEPHONE:
(916) 682-4788
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:75CENSUS: 26DATE:
12/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Director- Manuela TotahTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Silva met with Director Manuela Totah for the purpose of an unannounced random annual inspection. Upon arrival, there were three staff and 26 children present. During visit children were transitioning to outside time. Facility hours of operation are Monday through Friday from 6:30 AM to 6:00 PM.

LPA toured classrooms, restrooms, and outdoor play areas. Toileting facilities are in safe, sanitary, and operating condition. The floors appeared clean throughout the facility. Director stated there are no poisons on the premises. Toxic and hazardous items are inaccessible to children. Furniture and equipment are in good condition. All food was protected against contamination. Storage containers with solid waste have tight-fitting covers. Program provides morning snack and afternoon snack. Menus were posted. Drinking water was readily available to children both indoors and outdoors. LPA observed full legal signatures while reviewing the sign in and sign out sheets.

Three staff and four children's records were reviewed. Each child's file contained an emergency card and a medical assessment. At least one staff member present today has current Pediatric CPR and First Aid certification (exp. 1/24/2021). Mandated reporter training is current for all staff.

Incidental Medical Services was discussed. For IMS information see Evaluator Manual Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department.

Report continues on 809-C.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy SilvaTELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: CHAMPIONS @ ROY HERBURGER ELEMENTARY
FACILITY NUMBER: 343610212
VISIT DATE: 12/17/2019
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The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

LPA provided and discussed Effects of Lead Exposure brochure.

This facility evaluation report was reviewed and discussed with the Director. A Notice of Site Visit was provided and should remain posted for a period of 30 days for parental review. Director was encouraged to the visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining child care centers.

An exit interview was conducted and in the areas that were evaluated, no deficiencies were observed at the time of the inspection.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy SilvaTELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2