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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004219
Report Date: 08/06/2019
Date Signed: 08/06/2019 03:23:39 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 - FRANKLIN ELEMENTARYFACILITY NUMBER:
414004219
ADMINISTRATOR:TABORA, JOANNE, DIRFACILITY TYPE:
840
ADDRESS:2385 TROUSDALE DRIVETELEPHONE:
(650) 867-6046
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: 40DATE:
08/06/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Leila Rashid, Michele McLaughlinTIME COMPLETED:
03:45 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 conducted a case management inspection today. This is a self-reported unusual incident by the facility to licensing. On 7/19 around 2:20 pm, staff discovered from the two children that they had just gotten back from attempting to visit a friend on Trousdale Drive. Staff spoke with the two children immediately and found out the two children left the facility and came back to the facility without the staff's knowledge. Today LPA interviewed 2 staff members. Also, LPA attempted to interview the two children involved and the children were not available.
The staff said she went for a walk around the school with 3 children prior to the incident and at that time the two children were still in the playground. After she came back from the walk the 3 children joined the two children in the playground.
Although the staff does not know how long the two children were gone but estimated the time from the phone call she took during the walk which was 5-10 mins. Based on the information obtained today, there was a lack of supervision at the time of the incident. Therefore, the $500 civil penalty was issued today.

See next page for Type A citation.

The facility was advised to post and provide copies of this report to parents and guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents shall sign the LIC 9224 as proof of receipt.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2019
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 2
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 - FRANKLIN ELEMENTARY
FACILITY NUMBER: 414004219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2019
Section Cited
CCR
101229(a)(1)
1
2
3
4
5
6
7
101229(a)(1): Responsibility For Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1).Supervision shall include visual observation.
1
2
3
4
5
6
7
The Licensee has already taken action to correct the deficiency: Children were reminded not to go past the red cones. The facility had supervision training with all staff members on 7/23.
8
9
10
11
12
13
14
This requirement is not met as evidenced by confirmation that a lack of supervision occurred when two children left and came back to the facility without the staff knowledge. There were 3 staffs onsite that day.
This poses an immediate safety risk to children in care. $500 civil penalty was issued today.
8
9
10
11
12
13
14
An office meeting maybe scheduled.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2