414000839-7-19-2022-05-CC-HLEG-CGGUA3-20220719152403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414000839
Report Date: 07/19/2022
Date Signed: 07/19/2022 04:09:42 PM

Document Has Been Signed on 07/19/2022 04:09 PM - 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, 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: 16	DATE:	07/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Noel Trevisan		TIME COMPLETED:	04:00 PM

NARRATIVE

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On 7/19/2022, Licensing Program Analysts (LPA), Hanson Leong, made an unannounced annual visit to the Champions-John Muir Elementary facility. LPA was granted entry by the director, Noel Trevisan. LPA explained the purpose of the visit to the director. All facility’s staff members have had their criminal background checks cleared by Guardian except for one staff member. A review of the staff records revealed that one of the staff members did not have fingerprint clearance. LPA informed the director that the absence of fingerprint clearance will result in a Type A violation. LPA observed the director, teacher and one volunteer supervising sixteen children. From Monday to Friday, the hours of operation are 7:00 am. to 6:00 pm.

LPA and the Director thoroughly checked the facility for potential health and safety hazards. Toys, furniture, and learning materials are all age appropriate in all classrooms. LPA observed that the outside furniture and play structures are in excellent condition. Wood chips surround the outdoor play structures, absorbing any accidental falls. LPA observed that there were no bodies of water at the facility. All cleaning products, poisons, and other hazardous chemicals have been kept out of reach of children. The facility has smoke detectors, carbon monoxide detectors, fully charged fire extinguishers, centralized smoke alarms, and working phones. According to the director, there are no firearms or weapons in the facility.

LPA observed that the facility posted the required documents. (i.e., license, waivers, notification of parental rights, notification of personal rights, car seat law, emergency disaster plan, and daily activities).

LPA reviewed the records of ten children. All required forms were in the children’s file. The program uses a sign in / out sheet for authorized individuals to sign their children in and out. Children bring their own food to facility. or receiving food from the facility's catering company.

LPA reviewed the director's, teacher's, and volunteer's records. All required forms were in the staff files. A review of staff records revealed that two of the staff members are currently certified in CPR and First Aid. ***See Page 2 for continuation***

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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-JOHN MUIR ELEMENTARY (SA)	FACILITY NUMBER: 414000839
	VISIT DATE: 07/19/2022

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According to the Director, the Center simulates fire and earthquake drills monthly every six months. The last fire and earthquake drill were conducted on 3/9/2022.

Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA reviewed the new director's credentials and supporting documentation. Following a final review, Noel Trevisan, the new director, is determined to meet the department's requirements for a director by the LPA.

Incidental Medical Services (IMS) policy 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. 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA encouraged the Director to frequently visit the Licensing website at www.ccld.ca.gov for licensing regulations and new updates. Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

LPA Leong informed the director that this report dated 7/19/2022, documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Leong informed the licensee to provide a copy of this licensing report dated 7/19/2022 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. *** See Page 3 for continuation***

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/19/2022 04:09 PM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHAMPIONS-JOHN MUIR ELEMENTARY (SA)	FACILITY NUMBER: 414000839
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

101170(d)

(d) All individuals subject to criminal record review shall, be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on a review of the records, the licensee failed to comply with an employee's fingerprint clearance.which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2022
	Plan of Correction
1 2 3 4	Licensee will provide a copy of the employess live scan form to the department within 24 hours.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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-JOHN MUIR ELEMENTARY (SA)	FACILITY NUMBER: 414000839
	VISIT DATE: 07/19/2022

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A copy of this report, the “Notice of Site Visit”, and their appeal rights were given to the director.

A "Notice of Site Visit" must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and the report was reviewed with the new director, Noel Trevisan

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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