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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004214
Report Date: 09/24/2019
Date Signed: 09/24/2019 05:25:50 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-HOOVER ELEMENTARYFACILITY NUMBER:
414004214
ADMINISTRATOR:PAYNE-ALEX, TAMARAFACILITY TYPE:
840
ADDRESS:2220 SUMMIT DRIVETELEPHONE:
(408) 348-1610
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:56CENSUS: 27DATE:
09/24/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Leila RashidTIME COMPLETED:
05:40 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 Analyst (LPA) Marie Rodriguez made an unannounced Case Management visit in conjunction with the 3 Year Annual Required inspection to follow up on an unusual incident report received at CCLD office on September 13, 2019. The incident involves Child C1 getting injured after being pushed by Child C2 while playing on the playground.

LPA met with Site Director Leila Rashid and explained purpose of visit. LPA toured the physical plant were the incident occurred. LPA discussed the incident with Site Director who witnessed the incident. Based on Site Director's statement, C1 and C2 were playing the game of Tag with a bigger group of children when C2 pushed C1 down. Site Director followed procedure while tending to C1's injury. Site Director interviewed both children involved and provided the details of each interview to LPA. C1 and C2 were unavailable to interview at the time of visit. Site Director informed LPA that C1 was feeling better and that C1 and C2 were still playing together after the incident occurred.

Site Director discussed the incident with both C1 and C2's parents and any concerned parents who may have witnessed the Paramedics tending to C1. Site Director also spoke to the children in the program about the incident and how to prevent it from happening again in the future. Children will no longer play along the fence of the outdoor play area. Children were advised not to push each other hard while playing and if a child does so, their playground privilege will be taken away.

No deficiencies cited today.

This report was reviewed and discussed with Site Director Leila Rashid. A copy of report was provided.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) -26-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019
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 1