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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000476
Report Date: 08/22/2019
Date Signed: 08/22/2019 04:16:45 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-SANDPIPER ELEMENTARYFACILITY NUMBER:
414000476
ADMINISTRATOR:MCLAUGHLIN, MICHELEFACILITY TYPE:
840
ADDRESS:797 REDWOOD SHORES PARKWAYTELEPHONE:
(650) 780-7322
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY:75CENSUS: 20DATE:
08/22/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Michele McLaughlinTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Singh and Cowan met with director, Michele McLaughlin, for a case management inspection for an incident. Purpose of the inspection was explained. The facility self reported the on August 07, 2019, while playing in the play yard a child sustain injury.

During today's inspection, LPAs inspected the play yard and play structure for any health and safety hazard. LPAs observed the play structure is in good repair, without any loose parts. Director stated that on August 07, there were 20 to 22 children playing in the play yard, while two teachers and director were providing supervision. Per director, one child went up the slide but did not slide down the slide. Per director, the child jumped down the slide from the side of the slide. Per director, a teacher observed the child falling and approached the child. Per director, the child informed the teacher about the pain in the right arm. Per director, teacher contacted the parent and father of the child arrived at the facility very shortly and took the child to the hospital. Per director, it was informed that the child had minor fracture. During today's inspection, it was observed that facility followed the procedures and no violations of regulations were occurred.

No deficiencies are cited today. Copy of this report is reviewed and provided to the director. Notice of site visit is posted and shall remain posted for next 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2019
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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