414001443-6-9-2022-05-CC-BVAN-CF8W3G-20220609165556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414001443
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:57:07 PM

Document Has Been Signed on 06/09/2022 04:57 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-LINCOLN ELEMENTARY (SA)		FACILITY NUMBER:	414001443
ADMINISTRATOR:	JONES, ADELINE		FACILITY TYPE:	840
ADDRESS:	1801 DEVEREUX DRIVE		TELEPHONE:	(650) 697-7400
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	131	CENSUS: 38	DATE:	06/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:58 PM
MET WITH:	Shereen Najjar		TIME COMPLETED:	05:00 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	On June 9, 2022, Program Analyst (LPA) Van performed an unannounced mandated annual inspection and met with the substitute Director, Shereen Najjar, the Director of Champions' Mckinley site. (New Director Antionette Maxted-Goodman was absent due to a family emergency. LPA discussed Ms. Maxted-Goodman's director paperwork/qualifications with Director Shereen Najjar and provided the information on the missing documents to the Ms. Najjar.) The purpose of the inspection was explained to the Director. This facility is a school-aged after-school program that operates in the Lincoln Elementary School in Burlingame. The Center uses classrooms #8, #14, #15, the library, and the multipurpose room. Classrooms #8, library, and multipurpose room were not used today. At 3:05 pm, the children arrived. Three teachers and three aides supervised 38 children. The days and hours of operations during the school year are Monday to Friday, 7:00 am – 6:30 pm. The facility was inspected indoors and outdoors for Health and Safety hazards. The Center is clean, organized, in good repair, and has proper temperature and ventilation. Classrooms have age-appropriate toys and learning materials. Furniture appears steady and free from defects. The First Aid Kit is fully stocked. Emergency supplies are properly maintained and kept inaccessible to children. LPA observed all cleaning products and disinfectants are stored in the cabinets with child-proof locked. The facility has several restrooms (Girls and Boys). Restrooms are maintained clean, in good repair, and with adequate supplies. Staff uses a separate restroom located outside the office. The facility's food preparation area is clean.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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-LINCOLN ELEMENTARY (SA)	FACILITY NUMBER: 414001443
	VISIT DATE: 06/09/2022

NARRATIVE

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Per Director, the fire and earthquake drills are conducted at least once every six months. The drills were usually conducted in conjunction with the school, and the last drills were conducted on 1/14/2022. However, the staff did not document the drill. LPA inspected the outdoor play area for safety hazards and dangerous conditions. The play yard is completely fenced. LPA observed play area is equipped with a climbing structure and tether ball court. Drinking water is readily available indoors and outdoors for daycare children. The program provides afternoon snacks. Per Director, the facility has no children with medications this school year. Directors stated the facility has a medication box with a lock and key. In addition, Director understood that medications need to be in the original box, unaltered, and have the child's name. LPA also observed that the facility had posted the required forms. (i.e., License, waivers, Notification of Parent's Rights, and Notification of Personal Rights).

In today's inspection, LPA reviewed ten random samples of children's and staff records. According to the Director, the teacher assigned to the Kindergarten will come to the children's classroom and pick them up. Older children will line up on the ramp, the teacher will sign in all children, and a head count will be conducted before entering the classroom. All children had a medical assessment, and required licensing forms were completed. All staff has criminal record clearance. Teachers have records of valid Pediatric FirstAid/CPR cards in the file and the required immunization

The 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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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-LINCOLN ELEMENTARY (SA)	FACILITY NUMBER: 414001443
	VISIT DATE: 06/09/2022

NARRATIVE

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The Director 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 reminded the Director that as of September 1, 2016. A person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles. LPA observed that the facility has a record of required immunization of all staff.

The Director was informed about Mandated Reporter training available on the CCLD website. In addition to AB1207 Training required to complete every two years by all staff hired, a one-time General Training is also required. Training can be taken online at www.mandaterreporterca.com. Also, the Director was reminded of Pesticides training. Information on the DPR website at: www.cdpr.ca.gov/shoolipm/childcare

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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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-LINCOLN ELEMENTARY (SA)	FACILITY NUMBER: 414001443
	VISIT DATE: 06/09/2022

NARRATIVE

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During the inspection, LPA requested an update Designation of Responsibility (LIC 308); Mandated Reporter Training Certification for the new Director (Antionette Maxted-Goodman), and staff S1; Basic Pest management Certification for all staff; Incidental Medical Services (IMS) Plan; Immunization records, including MMR, TDAP, TB clearance, and Influenza for Antionette Maxted-Goodman.

No deficiencies were cited today. An exit interview was conducted, and the report was reviewed with the Director, Shereen Najjar. Today's report, June 9, 2022, and notice of site visit will be sent to the Director by email by the close of business on June 9, 2022. Confirmation of receipt is required. LPA informed the Director that the site visit notice must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC809 (FAS) - (06/04)

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