414000839-3-22-2023-05-CC-GLEG-CQSUMC-20230411154207

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 414000839
Report Date: 03/22/2023
Date Signed: 03/22/2023 02:51:04 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2023 and conducted by Evaluator Catrina Quimbo

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20230206141901

FACILITY NAME:	CHAMPIONS-JOHN MUIR ELEMENTARY (SA)		FACILITY NUMBER:	414000839
ADMINISTRATOR:	TREVISAN, NOEL		FACILITY TYPE:	840
ADDRESS:	130 CAMBRIDGE LANE		TELEPHONE:	(650) 797-4310
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	75	CENSUS: 27	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Noel Trevisan		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff make inappropriate comments in the presence of day care children.
Staff do not ensure that person who signs child in/out uses full legal signature.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On March 22, 2023 at approximately 1:15pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, complaint visit to Champions program operating at John Muir elementary school. LPA met with site supervisor, Noel Trevisan, and explained the purpose of the visit.

Present during LPA's visit included 3 staff members and 27 school age children. During investigation, LPA conducted classroom observations, interviewed random selection of children enrolled in Champions program, interviewed random selection of staff working in Champions program, interviewed random selection of parents and reviewed program documents.

More than one child interviewed stated they have heard Champions staff make an inappropriate comment in their presence. Child interviewed also stated they have observed an inappropriate message on a Champion's staff member's cell phone. Random selection of parent interviewed stated they have observed Champion's staff make an inappropriate comment in the presence of day care children. Champions employee handbook provided to LPA also states staff are to use appropriate and respectful language when representing Champions.

On 03/07/2023 and 03/22/2023, LPA reviewed sign in/out sheet and protocols for Champions program. LPA observed on sign in/out sheet, a child was not properly signed out of program. Staff did not ensure person who signed child out of program to use their legal signature.

(Continue Report on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2023 and conducted by Evaluator Catrina Quimbo

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20230206141901

FACILITY NAME:	CHAMPIONS-JOHN MUIR ELEMENTARY (SA)		FACILITY NUMBER:	414000839
ADMINISTRATOR:	TREVISAN, NOEL		FACILITY TYPE:	840
ADDRESS:	130 CAMBRIDGE LANE		TELEPHONE:	(650) 797-4310
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	40	CENSUS: 27	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Noel Trevisan		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are under the influence of marijuana while providing care and supervision.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 05-CC-20230206141901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CHAMPIONS-JOHN MUIR ELEMENTARY (SA)	FACILITY NUMBER: 414000839
	VISIT DATE: 03/22/2023

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

(Continued, Page 2)
Although the above allegation may have happened or is valid, based on LPA's observations, interviews and record review which were conducted, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with director, Noel Trevisan.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 05-CC-20230206141901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CHAMPIONS-JOHN MUIR ELEMENTARY (SA)	FACILITY NUMBER: 414000839
	VISIT DATE: 03/22/2023

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

(Continued, Page 2)
Based on LPA's observations, interviews and record review which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 12, are being cited. Please refer to 9099D for more information.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with director, Noel Trevisan.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 05-CC-20230206141901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 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: 03/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/24/2023 Section Cited CCR 101223(a)(1)	1 2 3 4 5 6 7	101223 Personal Rights (a)(1) The licensee shall ensure that each child is...To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Director will ensure all staff will receive additional training, reinforcing Champions Handbook procedures and protocols. Proof of training will be sent to LPA no later than 04/24/2023 by 5:00pm.
	8 9 10 11 12 13 14	Based on record review and interviews, children and parent stated they have observed and/or heard staff make an inappropriate comment in their presence. Employee Handbook also stated staff are to use appropriate and respectful language when representing Champions.	8 9 10 11 12 13 14
Type B 04/24/2023 Section Cited CCR 101229.1(a)(1)	1 2 3 4 5 6 7	101229.1 Sign in and Sign Out (a)(1) The person who signs the child...out shall use his/her full legal signature and shall record the time of day. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Director will ensure all staff will receive additional training, reinforcing classroom protocols and signing in/out procedures. Proof of training will be sent to LPA no later than 04/24/2023 by 5:00pm.
	8 9 10 11 12 13 14	Based on observations, record review and interviews, staff did not ensure person who signed a child out of program to use their legal signature.	8 9 10 11 12 13 14

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: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5