434414560-6-21-2021-07-CC-MSMS-C47TE4-20210621143918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414560
Report Date: 06/21/2021
Date Signed: 06/21/2021 02:39:26 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 AT ORCHARD ELEMENTARY SCHOOL		FACILITY NUMBER:	434414560
ADMINISTRATOR:	LISA BENNETT		FACILITY TYPE:	840
ADDRESS:	921 FOX LANE		TELEPHONE:	(408) 944-0397
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95131
CAPACITY:	60	CENSUS: 8	DATE:	06/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Lisa Bennett		TIME COMPLETED:	02:45 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 Lisa Bennett, director, for an unannounced Required - 1 year inspection. LPA toured the Facility both indoor and outdoor areas of the Facility during today's inspection. LPA notes that the Facility is located on the campus of Orchard Elementary School and licensed in Rooms 24 & 25 plus the Library and Multuipurpose 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 (posted at least one week in advance), and Activity Schedule. There are no active waivers on file. A review of staff records on June 18, 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 Lisa 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 eleven 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. There is at least one staff (Lisa & teacher) with current CPR and First Aid certifications on file. Lisa 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 06/21/2021):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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 3

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 AT ORCHARD ELEMENTARY SCHOOL	FACILITY NUMBER: 434414560
	VISIT DATE: 06/21/2021

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
26
27
28
29
30
31
32

CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 06/21/2021):

LPA observed that the teacher/child ratio was in compliance during today's inspection. Lisa understands the conditions, limitations, and capacity specifications of the Facility license. Lisa understands that children shall be visually supervised at all times. LPA observed one teacher and Lisa (director) with eight school age children in Room 24 during today's inspection. Room 25, Library, and Multipurpose Room was not in use during today's inspection. The Facility is aware of the required sign in and sign out procedures for school age children who arrive on their own. Lisa states that all school age children are picked up by their parent(s)/guardian(s) and no children are allowed to leave the Facility on their own.

LPA observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. Lisa states that the Facility has a third-party cleaning service that cleans the Facility Monday through Friday in the evenings. Lisa 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 Room 24 and in the outdoor playground area via water fountains, 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. Lisa 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. The Facility has trash cans with tight fitting lids for solid waste. Cleaning supplies are inaccessible to the children and stored in high cabinets and under the sink area in Rooms 24 & 25 inaccessible to children. Any medications at the Facility are stored in Room 24.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 06/21/2021):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 AT ORCHARD ELEMENTARY SCHOOL	FACILITY NUMBER: 434414560
	VISIT DATE: 06/21/2021

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
26
27
28
29
30
31
32

CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 06/21/2021):

The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. There is adequate equipment and supplies for children outdoors. LPA observed that the outdoor equipment is age appropriate and in good condition. Shade is provided by trees and building overhangs. There is sufficient resilient materials in the outdoor playground area. LPA did not observe any bodies of water.

Licensing Forms, Title 22 Regulations and information can be obtained through the internet at www.cdss.ca.gov.

LPA conducted an exit interview with Lisa prior to the conclusion of today's inspection and advised her that no deficiencies issued during 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: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3