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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410632
Report Date: 03/07/2023
Date Signed: 03/07/2023 03:06:12 PM


Document Has Been Signed on 03/07/2023 03:06 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:CHAMPION KINDER INTERNATIONAL SCHOOLFACILITY NUMBER:
434410632
ADMINISTRATOR:YANG, JANEFACILITY TYPE:
850
ADDRESS:1055 SUNNYVALE-SARATOGA ROADTELEPHONE:
(408) 838-3333
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:235CENSUS: 14DATE:
03/07/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Jennifer LeeTIME COMPLETED:
03:20 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), Oscar Huang, conducted an unannounced case management inspection in response to a lead testing completed with an exceedance level. Director, Jane Yang is out for launch. LPA met with manager officer, and explained the nature of today's inspection to her.

During today's inspection LPA Huang requested the following documents; Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report. The lead exceedance readings was found from drinking faucet of the classroom 7 of 7.1 ppb. LPA Huang conducted a tour to classroom 7 which was no longer in service since March 17, 2020, the entrance door was locked and inaccessible. LPA observed that the drinking faucet water pipe was shutoff from the water source and no longer in use.

Office manager Lee stated due to low enrollment that the facility is currently using only 2 classrooms out of 10, and therefore there is no needs to use room 7 in the near future. If needed the drinking water in room 7 will be fixed and retested.

Type B deficiency cited, exit interview conducted, and a copy of this report was reviewed with the office manager, Jennifer Lee. Appeal rights were reviewed and provided.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE CENTER, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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 2


Document Has Been Signed on 03/07/2023 03:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: CHAMPION KINDER INTERNATIONAL SCHOOL
FACILITY NUMBER: 434410632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited

1
2
3
4
5
6
7
Lead Testing Written Directives section 101700.3 (b)(1), a result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
During today's inspection LPA Huang requested the following documents; Self-Certification LIC9275, Sampling Checklist Form LIC9276, Facility Sketch LIC 999, fully labeled with locations of all water outlets, and full lead report.
8
9
10
11
12
13
14
This exceedance level found in the
classroom 7 drinking faucet was 7.10. This poses a potential risk to the Health, Safety, or Personal Rights of children in care.
8
9
10
11
12
13
14
The drinking water faucet located in room 7 was disconnected from the water source and no longer used, Room & is no in use for almost 3 years.

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: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2