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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414559
Report Date: 09/17/2019
Date Signed: 09/17/2019 03:40:41 PM

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:CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARYFACILITY NUMBER:
434414559
ADMINISTRATOR:RUBY ALTERFACILITY TYPE:
850
ADDRESS:921 FOX LANETELEPHONE:
(408) 944-0395
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY:42CENSUS: 18DATE:
09/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Maria HernandezTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mel Matos and Araceli Almaraz met with Maria Hernandez, director, for an unannounced annual/random inspection. The preschool age program is Licensed in Rooms 1, 2 ,& space between Rooms 1 & 2 on the campus of Orchard Elementary School. The Facility also has a school age program (#434414560) that is licensed on the same campus in Rooms 24, 25, library, and multipurpose room. Maria Hernandez states that Ruby Alter is no longer the director and that she has been the director of the preschool & school age programs since November 2017. LPAs note that there is no paperwork on file reflecting the change of director.

LPAs toured the Facility both inside and outside during today's inspection. LPAs observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus, and Activity Schedule.

LPAs observed that all both rooms are clean and safe for all children and staff; however, there is some frayed carpeting in Room 1 that can pose a potential tripping hazard to children and staff. Maria states that the Facility has a third-party cleaning service that cleans the Facility Monday through Friday in the evenings. Drinking water is readily available for the children in each room and in the outdoor playground area via drinking fountains & water dispensers. LPAs observed solid waste containers with tight-fitting lids in each room. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Maria states that there are no weapons or firearms on the premises. There is a functioning carbon monoxide detector in the Facility.

LPAs reviewed ten children's and four staff (1 director, 2 teachers, & 1 aide) files during today's inspection Each child's file reviewed contains the Information and Emergency Information form (LIC 700). All staff files reviewed contain the required transcripts/verification of experience. There is at least one staff that has current CPR and First Aid certifications on file. Maria understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips).

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 09/17/2019):
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2019
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 4
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: CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY
FACILITY NUMBER: 434414559
VISIT DATE: 09/17/2019
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 01/09/2017):

A review of staff records on September 16, 2019 indicates that NOT all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded Maria of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violations within a 12 month period.

LPAs observed that Nikole Miller has fingerprint clearances associated to the school age license (#434414560) but not to the preschool license. Karina Cruz-Mendez has fingerprint clearances associated one Facility within the same corporation but not to the preschool license.

LPAs observed that the teacher/child ratio was in compliance during today's inspection. LPAs observed 6 preschool children in Room 1 with 1 teacher and 12 preschool children with 1 teacher and 1 aide in Room 2 during today's inspection. Maria understands the conditions, limitations, and capacity specifications of the Facility license. Maria understands that children shall be visually supervised at all times.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored in high cabinets & locked cabinets inaccessible to children. The Facility does not administer any medication at this time.

LPAs observed all furniture and equipment is in good condition and safe for the children. The playground areas utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPAs observed that the outdoor equipment is age appropriate and in good condition. LPAs did not observe any bodies of water. LPAs notes that Rooms 1 & 2 have playground space located adjacent to those rooms. There are no climbing structures in the preschool playground areas.

LPAs conducted an exit interview with Maria and advised her that the following "Type B" deficiencies are cited on the attached page (809-D). Appeal rights were provided to Maria prior to the conclusion of today's inspection.
A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY
FACILITY NUMBER: 434414559
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2019
Section Cited

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
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Request a transfer of a criminal record clearance as specified in Section 101170(f). This requirement was not met as evidenced by: Nikole Miller & Karina Cruz-Mendez have criminal record clearances; however, the Facility failed to transfer their clearances to the Facility license.
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This presents a potential risk to the health/safety of 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY
FACILITY NUMBER: 434414559
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2019
Section Cited

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Reporting requirements: The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).
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This requirement is not met as evidenced by: Maria Hernandez has been the director since November 2017 & the change of director was not reported to the Dept. This presents a potential risk to the health/safety of children in care.
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Type B
10/15/2019
Section Cited

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Buildings & Grounds: The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement
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is not met as evidenced by: There is some frayed carpeting in Room 1 that can pose a potential tripping hazard to children and staff. This presents a potential risk to the health/safety of 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4