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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414559
Report Date: 04/06/2023
Date Signed: 04/06/2023 10:50:42 AM

Document Has Been Signed on 04/06/2023 10:50 AM - It Cannot Be Edited

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:NICOLE BOTELHOFACILITY TYPE:
850
ADDRESS:921 FOX LANETELEPHONE:
(408) 944-0395
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 42TOTAL ENROLLED CHILDREN: 26CENSUS: 20DATE:
04/06/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Nicole BotelhoTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Mel Matos met with Nicole Botelho, director, for an unannounced case management inspection. Purpose of today's inspection: discuss the facility license and age ranges of the license.

The current facility license states that the facility serves children ages 3-5 years of age. LPA advised Nicole that the facility would have to submit an updated Application for a Child Care Center License (LIC 200A) along with an updated parent handbook and admission agreement if the facility elected to change the age range of children that it serves.

LPA advised Nicole that the facility can elect to serve children from 2 years to entry into Kindergarten; however, the pertinent paperwork noted above would need to be submitted to the Department prior to any change taking effect.

Nicole states that she understands the requirements and will pass on the information to her manager.

Exit interview conducted and report was reviewed with the Director, Nicole Botelho. No deficiencies cited during today's inspection. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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