414004214-6-9-2022-05-CC-BVAN-CF8QAZ-20220609120048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004214
Report Date: 06/09/2022
Date Signed: 06/09/2022 12:01:47 PM

Document Has Been Signed on 06/09/2022 12:01 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-HOOVER ELEMENTARY		FACILITY NUMBER:	414004214
ADMINISTRATOR:	RASHID, LEILA		FACILITY TYPE:	840
ADDRESS:	2220 SUMMIT DRIVE		TELEPHONE:	(650) 579-5664
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	98	CENSUS: 4	DATE:	06/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Vanessa Romero		TIME COMPLETED:	12:15 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 new Director, Vanessa Romero. The purpose of the inspection was explained to the Director. LPA informed the Director to submit the required Director paperwork/qualifications to the Licensing office. This facility is a school-aged after-school program that operates in the Hoover Elementary School in Burlingame. The school approved the Center to use classrooms #1, #17, #18, the library, and the multipurpose room. Classrooms #17 and #18 were not used today. The days and hours of operations are Monday to Friday, the morning program from 7:00 am to 8:30 am the after-school program from 2:00 pm to 6:30 pm. Today two staff including the Director, were supervising four children. The Director and LPA inspected the facility for potential health and safety hazards. LPA observed the facility had signed in and out records with complete parents' signatures, and all signatures matched the number of children in care. All classrooms have age-appropriate games, books, and equipment in good repair. Classrooms have acceptable ventilation and ample lighting. Currently, the children are utilizing the storage bin for their belonging. Director stated the children's cubbies have been ordered and will be installed before next school year start. The facility has a smoke detector, a fully charged fire extinguisher, and carbon monoxide. There are no pools, spas, or other bodies of water at the facility. All cleaning solutions, poisons, and other dangerous chemicals are stored in an area inaccessible to children. LPA observed the unused electrical outlets have covers and installed. All the bathrooms, toilets, and sinks are clean and well sanitized. All solid waste bins have a suitable tight-fitted lid on top, and the facility has water bottles stored in the refrigerator readily available for children. The outdoor playground area is in good repair and completely fenced for supervision. The play structure is age-appropriate and in good condition, with sufficient cushioning underneath.

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-HOOVER ELEMENTARY	FACILITY NUMBER: 414004214
	VISIT DATE: 06/09/2022

NARRATIVE

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In today's inspection, LPA reviewed random samples of children's and staff records. The teacher will sign in all children, and a head count will be conducted prior to 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. 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). The Director stated that Fire and Earthquake drills are done at least once every six months, and the last drills were conducted on 1/17/2022.
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 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
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.
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

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-HOOVER ELEMENTARY	FACILITY NUMBER: 414004214
	VISIT DATE: 06/09/2022

NARRATIVE

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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.

During the inspection, LPA requested a new Emergency Disaster Plan (LIC 610), Designation of Responsibility (LIC 308), Personnel Report (LIC 500), Incidental Medical Services (IMS) Plan, and Basic Pest Management Training Certification for Director and teacher. All requested documents will be submitted to Licensing by June 17, 2022.

No deficiencies were cited today. An exit interview was conducted, and the report was reviewed with the Director, Vanessa Romero. Today's report, June 9, 2022, and notice of site visit will be sent to the Director by email at CHOOO690@discoverchampions.com 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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