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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413753
Report Date: 10/25/2019
Date Signed: 10/25/2019 10:55:18 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CHAMPION SCHOOLFACILITY NUMBER:
434413753
ADMINISTRATOR:MUNA KHANAFACILITY TYPE:
850
ADDRESS:5670 CAMDEN AVENUETELEPHONE:
(408) 390-3490
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:60CENSUS: 13DATE:
10/25/2019
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Muna KhanaTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Rangel met with owner Muna Khana and her husband Sandeep Khana. The purpose of the inspection is to review ongoing facility efforts to maintain compliance per the Informal Meeting conducted between the owner and Community Care Licensing Management on 10/08/18. As a stipulation of the agreed upon plan, the facility will be under increased monitoring from Community Care Licensing.

LPA toured certain areas of the facility and reviewed ten new children's files. LPA observed that the facility is not in compliance with Assembly Bill (AB) 633 with signed LIC 9224 Acknowledgement of Receipt of Licensing Reports. LPA observed the physical plant and observed that facility has all working toilets and sinks. LPA observed the sign in/out sheets, immunizations of children on the PM 286 and mandated reporter training for the new employee. When the facility serves milk, the facility complies with serving 1% or fat free milk to children. LPA discussed with Muna Khana expectations for ongoing compliance.

Deficiency cited today. Appeal rights printed and reviewed. LPA reviewed sign in and out regulations 101229.1 with licensee and requirements for staff files. Notice of Site Visit has been issued and must remain posted for 30 consecutive days. Exit interview conducted with Ms. Khana. $250.00 civil penalty assessed today.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2019
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CHAMPION SCHOOL
FACILITY NUMBER: 434413753
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2019
Section Cited

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A licensed child day care facility shall provide to the parents or legal guardians of each child receiving services in the facility copies of any licensing document pertaining to a
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conference conducted by a local licensing agency management representative with the licensee in which issues of noncompliance are discussed. This requirement was not met as evidenced by the Licensee not having signed copies of the Acknowledgement of Receipt of Licensing Reports (LIC 9224) for the five new students from the 10/8/18 office meeting. This poses a potential Safety risk to children in care.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2019
LIC809 (FAS) - (06/04)
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