434414559-9-10-2021-07-CC-MSMS-C6QVE3-20210910162140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414559
Report Date: 09/10/2021
Date Signed: 09/10/2021 04:21:50 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 ELEMENTARY		FACILITY NUMBER:	434414559
ADMINISTRATOR:	RUBY ALTER		FACILITY TYPE:	850
ADDRESS:	921 FOX LANE		TELEPHONE:	(408) 944-0395
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95131
CAPACITY:	42	CENSUS: 8	DATE:	09/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Nicole Botelho		TIME COMPLETED:	04:30 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) Mel Matos met with Nicole Botelho, director, for an unannounced Required - 1 year inspection (KIT 2). LPA toured the Facility both indoor and outdoor areas of the Facility during today's 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. LPA 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. A review of staff records on September 10, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded Nicole 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. LPA reviewed ten children's and two staff files (1 director and 1 teacher) 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/immunization records and Health Screening Report. All staff have current certificates of completion of the Mandated Reporter Training for Child Care Workers on file. Nicole and one teacher has current CPR and First Aid certifications on file. Nicole 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).

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

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: CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY	FACILITY NUMBER: 434414559
	VISIT DATE: 09/10/2021

NARRATIVE

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LPA observed that the teacher/child ratio was in compliance during today's inspection. Nicole understands the conditions, limitations, and capacity specifications of the Facility license. Nicole understands that children shall be visually supervised at all times. LPA observed one teacher with 15 napping children in Room 1 and one teacher with 5 napping children in Room 2 during today's inspection. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in the director’s office area.

LPA observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. Nicole states that the Facility has a third-party cleaning service that cleans the Facility Monday through Friday in the evenings. Nicole understands that the Facility must be kept free of flies and other insects & rodents. LPA observed that all furniture and equipment is in good condition and safe for the children. Drinking water is readily available for the children in each Room and in the outdoor playground areas via water dispensers/disposable cups/water bottles. LPA 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. Nicole states that there are no weapons or firearms on the premises. The Facility has functioning carbon monoxide detectors.

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 & in janitor's closet, located near the kitchen area, inaccessible to children. Any poisons are stored in the locked janitor closet, located near the kitchen area. Any medications at the Facility are stored in each individual classroom.
The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. However, sections 3-10 (starting from chain link fence towards wooden gate) of the fenced area dividing the off limits area of the playground, located on the left end of the playground closest to the Facility entrance, needs to be repaired/replaced since the sections are not secure and safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. Shade is provided by trees and building overhangs in the playground. LPA notes that Rooms 1 & 2 have playground space located adjacent to those rooms. There are no climbing structures in the preschool playground areas. LPA did not observe any bodies of water. LPA conducted an exit interview with Nicole and advised her that the following "Type B" deficiency is cited on the attached page (809-D). Appeal rights were provided to Nicole 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 Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

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: CHAMPIONS PRESCHOOL @ ORCHARD ELEMENTARY	FACILITY NUMBER: 434414559
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/01/2021 Section Cited	1 2 3 4 5 6 7	Outdoor Activity Space: The playground shall be enclosed by a fence to protect children and to keep them in the outdoor activity area. The fence shall be at least four feet high. This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Sections 3-10 of the fenced area dividing the off limits area of the playground, located on the left end of the playground closest to the Facility entrance, needs to be repaired/replaced. This presents a potential risk to the health/safety of children.	8 9 10 11 12 13 14
	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: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC809 (FAS) - (06/04)

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