<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001497
Report Date: 02/08/2023
Date Signed: 02/08/2023 03:15:18 PM


Document Has Been Signed on 02/08/2023 03:15 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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CHAMPIONS AT PORTOLAFACILITY NUMBER:
414001497
ADMINISTRATOR:HASAN, HINDFACILITY TYPE:
840
ADDRESS:300 AMADOR AVE., ROOM #1TELEPHONE:
(650) 440-1371
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:42CENSUS: 28DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Hind HasanTIME COMPLETED:
03:30 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 February 8, 2023 at approximately 1:20pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with director, Hind Hasan, and explained the purpose of the inspection.

Champions program is an after school program that operates at Portola Elementary School in Room A (#77) only. Children enrolled in program attend elementary school. Present during LPA's visit included 3 staff (including director) and 28 school age children. Facility is operating within capacity limits and ratio during LPA's visit. Hours of operation are Monday through Friday 7:00am to 8:00am and 1:00pm to 6:00pm.

With director, LPA inspected day care areas being used for health and safety hazards. Entire facility has a smoke alarm system installed and implemented through school district. Classroom is equipped with multiple fully stocked first aid kits, fully charged fire extinguisher and a working carbon monoxide detector.

LPA observed classroom to be well ventilated and to have age appropriate equipment and furniture. Classroom is equipped with a variety of age appropriate toys and materials that were in good working condition. Storage for children's belongings is located inside the classroom, labeled with each child's individual names. LPA observed poisons, chemicals and cleaning solutions were made inaccessible in classroom's high shelves and/or locked behind child safety locked cabinets. Classroom is equipped with a school district garbage bin that has a tight fitting lid that is disposed of daily. Classroom also includes an accessible sink. Water does not produce water that is warmer than 120 degrees Fahrenheit.

There are two, single use bathrooms located in the classroom, exclusive for Champions program's use. Bathrooms allow for individual privacy. LPA observed bathrooms to be in proper working condition, equipped with appropriate sanitation products.
(Continue Report on Page 2...)
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAMPIONS AT PORTOLA
FACILITY NUMBER: 414001497
VISIT DATE: 02/08/2023
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...)
Outdoor area for Champions use is located directly outside classroom. Outdoor area is enclosed with an at least 4 ft. high fence. Outdoor area does not include any pools, spas or bodies of water on site. Outdoor toys and materials are stored in outdoor area, located and locked in Champions shed.

Program provides dry, afternoon snacks that are stored in classroom. Children have access to water indoors and outdoors with children's individual water bottles that can be refilled on site through a filtered water station. Children who do not have a water bottle are provided disposable cups.

Children are signed into after school program through Champions staff. Children's authorized representatives sign children out with written signatures. Required licensing documentation is properly posted and available for review in the classroom. Emergency drill are conducted and documented properly. Last emergency drill was conducted 02/02/2023.

LPA reviewed facility records that included 5 random children's files and 3 staff member's files (whom were present during inspection) which were complete. Children's files have record of emergency identification information on file. All staff on site have a current Mandated Reporter certification and current CPR/First Aid certification. Director's CPR/First Aid certificate is current and will expire 09/2023.

Facility was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

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.
(Continue Report on Page 3...)
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAMPIONS AT PORTOLA
FACILITY NUMBER: 414001497
VISIT DATE: 02/08/2023
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 3...)
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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

No deficiencies were issued under CCR, Title 22, Division 12.

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.

Due to no ink on LPA's portable printer, LPA was unable to provide a hard copy of report to licensee. LPA to email copy of report to licensee. Acknowledgement of receipt of report is required.

Exit interview conducted and report was reviewed with director, Hind Hasan.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3