414000839-7-21-2021-05-CC-JSAI-C55SWQ-20210721141443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414000839
Report Date: 07/21/2021
Date Signed: 07/21/2021 02:15:11 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-JOHN MUIR ELEMENTARY (SA)		FACILITY NUMBER:	414000839
ADMINISTRATOR:	ISLA, RHONDA		FACILITY TYPE:	840
ADDRESS:	130 CAMBRIDGE LANE		TELEPHONE:	(650) 797-4310
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	75	CENSUS: 21	DATE:	07/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Director Rhonda Isla		TIME COMPLETED:	12:45 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 Analysts (LPA) Jyoti Saini met with Director Rhonda Isla for an unannounced Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the director. In addition to the director, there are 21 children and 3 staff present today. The facility operates Monday - Friday from 8:00 AM to 5:00 PM in portable #20 on the John Muir Elementary School Campus. The facility was inspected indoor and outdoor today for health and safety hazards and the following was observed; There are no bodies of water, firearms, or weapons on the premises. The center is in good condition with proper temperature and ventilation and is free of any hazards. All furniture is in good repair. The Center has age-appropriate toys and equipment. A first aid kit and a first aid backpack are available. The outdoor play area is fenced for supervision. The play structure is age-appropriate and in good condition. There are 2 bathrooms in the portable with 2 toilets and 2 sinks in each. The bathrooms appear to be safe, sanitary, and free of any hazardous items. There is drinking water readily available for children. The program provides daily snacks and lunch. The classroom has appropriate postings. The last Emergency Drill was conducted on 07/07/2021 and is properly logged.

LPA reviewed sign-in and out sheet. The center has a complete record of sign-in/out sheets by an authorized pick up person. There is a working fire alarm system at the elementary. The room has a working smoke and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone available.

see page 2...

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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

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-JOHN MUIR ELEMENTARY (SA)	FACILITY NUMBER: 414000839
	VISIT DATE: 07/21/2021

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
26
27
28
29
30
31
32

Page 2...

LPA reviewed Seven children files and were complete. All children have a record of emergency identification information on file. Three staff records reviewed were complete. All staff has a criminal record clearance on file. The staff has a current Pediatric First Aid/CPR certificate on file. All staff has taken Mandated Reporter training.

During inspection,

• Site Director was provided information regarding Incidental Medical Services (IMS). Per Director there are no services currently being provided to children.

For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Section 101226. When any IMS is provided, a plan for providing IMS must be submitted to the Department.

• Site Director was reminded as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.662.

• Site Director was reminded about Mandated Reporter Training available on the CCLD website. Training must be completed every two years. (Websites: www.ccld.ca.gov or www.mandatedreporterca.com)

• Site Director was reminded about the Provider Information Notices (PINs) on the CCLD website.

>No deficiencies were cited today under Title 22 Division 12 of the Ca. Code of Regulations.

> This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit.
This report is emailed to the director at ch001431@discoverchampions.com with a request for reply showing proof of receipt.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2