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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620594
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:17:01 AM


Document Has Been Signed on 01/31/2023 11:17 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:CHAMPIONS @ MARION MIXFACILITY NUMBER:
343620594
ADMINISTRATOR:PEREZ, MELISSAFACILITY TYPE:
840
ADDRESS:4730 LAGUNA PARK DRTELEPHONE:
(916) 430-7422
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:60CENSUS: 6DATE:
01/31/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Diana LavatoTIME COMPLETED:
12:00 PM
NARRATIVE
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On 01/31/2023, Licensing Program Analyst Katy Maestas (LPA) conducted a field visit to the facility for the purpose of a case management inspection. LPA arrived at the facility and was met by a teacher at the entrance of the facility. LPA disclosed the purpose of the inspection and was granted entrance into the facility and met Director Diana Lavato (D1). LPA toured 2 classrooms and observed 6 school-aged children being supervised by 2 adults. LPA accessed Guardian and ensured that all required adults were background cleared and associated to the license.

The facility's water was tested in December 2023; a combination water fountain and sink as well as a sink in the kitchen tested positive for elevated levels of lead. The 3 water outlets were replaced on 01/14/2023 but are not yet fully flushed nor have they been re-tested. LPA ensured that the water outlets are closed and not available for consumption. D1 stated that she will purchase purified water with a dispenser for drinking and cooking until the outlets are remediated and re-tested. D1 understands that LPA must be notified after re-testing and emailed the results of the test.

As a result of the water testing positive for lead, a deficiency was cited on subsequent page 809D. An exit interview was conducted and the report was reviewed with D1. Licensee Appeal Rights were provided to D1. A Notice of Site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.


SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Nola MaestasTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/31/2023 11:17 AM - 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833


FACILITY NAME: CHAMPIONS @ MARION MIX
FACILITY NUMBER: 343620594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2023
Section Cited

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Lead Testing (b)(1) A result which values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by:
The water results from lead testing in December 2022 revealed that the facilty
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LPA observed that the affected water outlets are no longer in use. D1 will email LPA the required forms: LIC 9275 and LIC 9276 before 5 pm on 02/01/2023. D1 will purchase purified drinking water for the facility. The water outlets will be flushed and re-tested. D1 understands
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had elevated levels of lead in 3 water outlets that were used for humane consumption. This is a potential health and safety risk to the children in care.
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that she must keep LPA apprised of the remediation and re-testing process.

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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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Nola MaestasTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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