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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004219
Report Date: 12/17/2020
Date Signed: 12/17/2020 12:52:01 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:137CENSUS: 29DATE:
12/17/2020
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Samantha PachecoTIME COMPLETED:
01:00 PM
NARRATIVE
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Due to the COVID-19 health crisis and shelter in place order, a tele-inspection was conducted. Licensing Program Analyst (LPA) Van met with the new Site Director, Samantha Pacheco, via Facetime Meeting, responding to an unusual incident self-reported to the Department on Sept 30, 2020. During the inspection, LPA also discussed with Ms. Pacheco the required Director's paperwork and qualification to be submitted to the Department to update her status as a new Site Director.

Along with the Director, LPA evaluated the physical space where the incident occurred, interviewed teachers involved that had direct knowledge of the incident. Based on the interview and facility report, it was determined that a lack of care and supervision had occurred on Sept 30, 2020. C1 was not properly handoff from one teacher to another during the transition, which left C1 unattended in a classroom. The error was due to the lack of communication among the two staff members.

Per Director, on Oct 6, 2020, a mandatory staff meeting was conducted. The agenda included Supervision, Policies & Procedures, and different type of Supervision scenarios for the staff members to engage in. Confirmation between the two teachers during the transition handoff is now required.

As a result, the following Title 22 deficiency is being cited on the next page. An exit interview was conducted; Plans of corrections were reviewed and developed with the Director. Appeal Rights were provided and discussed with the Director. Reports citing Type A violations are to be provided to parents/guardians of children currently enrolled and parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020
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 - FRANKLIN ELEMENTARY
FACILITY NUMBER: 414004219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2020
Section Cited

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101229 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision...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).
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This requirement is not met, as evidenced by the staff interview and facility incident reports. C1 was not properly handoff from one teacher to another during the transition, which left C1 unattended in a classroom. The error was due to the lack of communication among the two staff members. This poses an immediate health and safety risk to children in care.
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Training materials and staff-training attendance were received. POC is cleared on 12/17/2020.

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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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2020
LIC809 (FAS) - (06/04)
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