414000082-10-8-2019-05-CC-CINO-BGRU8C-20191008152119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414000082
Report Date: 10/08/2019
Date Signed: 10/08/2019 03:21:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	CHAMPIONS-LAS LOMITAS ELEMENTARY (SA)		FACILITY NUMBER:	414000082
ADMINISTRATOR:	DANG, THU-HANG T.		FACILITY TYPE:	840
ADDRESS:	299 ALAMEDA DE LAS PULGAS		TELEPHONE:	(650) 250-3658
CITY:	ATHERTON	STATE: CA	ZIP CODE:	94027
CAPACITY:	90	CENSUS: 34	DATE:	10/08/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Program Manager, Sharon Pfeiffer		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Cindy Interiano, met with Program Manager, Sharon Pfeiffer. Purpose of the inspection was explained and was for an Annual/Random inspection. Program operates on the Las Lomitas Elementary School Campus in Champions Room #3 (aka 'Building 2), Room#37, and #39. Program operates M-F, 7a-8:10a, and 1:25p-6p, during the School District calendar and M-F, 7a-6p during School breaks. Present during inspection was Program Manager and 5 Staff supervising 34 School age children. Facility was inspected indoors and outdoors for Health and Safety hazards. Classrooms have age appropriate toys and equipment that are in good repair. Bins are used to store Children’s belongings. Program has exclusive, scheduled use of sections of the Elementary School Playground, Grass area, and Playground. Children are not allowed to go beyond the set boundaries of the playground, unless supervised by Staff. Outdoor play area is free of debris and dangerous conditions. All outdoor toys and equipment are age appropriate and in good repair. Classroom is equipped with a smoke and carbon monoxide detector and a fire extinguisher. Classroom has proper ventilation and sufficient lighting. Program has exclusive, scheduled use of 3 accessible Boys' and Girls' restrooms. Restrooms are maintained clean, in good repair, and with adequate supplies. Staff restrooms are maintained inaccessible to children. First Aid Kit and Emergency supplies are properly maintained and kept inaccessible to children. Medications are maintained in the child’s assigned classroom and is kept with Guardian consent form, Doctor’s prescription and a log (when administered). Last Emergency drill was conducted on 09/30/19 and is properly logged. Cleaning products and toxins are maintained inaccessible to children. Drinking water is readily available indoors and outdoors. Program provides daily snacks and children bring their own meals. All mandatory postings properly posted near the main entrance of the classrooms. Sign in sheet was reviewed and is complete and up to date ‘check in’ and Sign out signatures for After school. See Page 2. . .

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHAMPIONS-LAS LOMITAS ELEMENTARY (SA)	FACILITY NUMBER: 414000082
	VISIT DATE: 10/08/2019

NARRATIVE

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Page 2. . .

During the inspection,
*Incidental Medical Services (IMS) policy was discussed.
*Facility was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Program Manager was reminded of Pesticides training. Information on the DPR website at: www.cdpr.ca.gov/shoolipm/childcare.
*Program Manager was advised of the new Lead Bill (effective 01/01/19), requiring Facilities to distribute a two-page flyer to Guardians with information on lead poisoning facts.
*Program Manager was reminded about the Provider Information Notices (PINs) on CCLD website.
*Program Manager was reminded about of Mandated Reporter Training available on CCLD website.

***No deficiencies were cited against the facility under CCR,Title 22, Div. 12, Ch. 1. ***

>This report and rights to comment and appeal were discussed with Program Manager. This report must be available in the facility for public review. Notice of site inspection was posted. Program Manager was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019

LIC809 (FAS) - (06/04)

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