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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414560
Report Date: 08/15/2022
Date Signed: 08/15/2022 10:43:11 AM


Document Has Been Signed on 08/15/2022 10:43 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 AT ORCHARD ELEMENTARY SCHOOLFACILITY NUMBER:
434414560
ADMINISTRATOR:LISA BENNETTFACILITY TYPE:
840
ADDRESS:921 FOX LANETELEPHONE:
(408) 624-0534
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY:60CENSUS: 3DATE:
08/15/2022
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anjelica Del ToroTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Mel Matos, met with Anjelica Del Toro, area manager, for an announced case management inspection to the Facility today in response to a request submitted by the Facility to drop Rooms 24 & 25 and add Boardroom, Pod "D", and Pod "E" to the existing school age license. The Facility is currently licensed in Rooms 24, 25, Multipurpose Room, and Library. The licensed capacity remains unchanged. The school age program is in operation from 6:30 AM to 6 PM during school recess periods. The school age program will operate from 6:30 AM to 11 AM and 2:20 PM to 6 PM (except Wednesday: 12:20 PM to 6 PM) during the regular school year.

The school age program is located on the campus of Orchard Elementary School (functioning elementary school) and is thus exempt from indoor and outdoor square footage requirements, sink/toilet ratios, isolation space, and fencing requirements. A capacity letter (394 school age children for the Multipurpose Room, 299 school age children for the Library, and 36 for the Boardroom, 68 for Pod "D", and 74 for Pod "E" from the Orchard School District is on file.

LPA toured the Multipurpose Room, Library, Boardroom, Pod "D", and Pod "E" and the playground areas during today's inspection. LPA observed sufficient chairs, tables, and cubbies in the Multipurpose Room, Library, Boardroom, Pod "D", and Pod "E". Boardroom, Pod "D", and Pod "E" are the main rooms to be used by the Facility. The Library and Multipurpose Rooms are used as overflow rooms for group activities. There is adequate equipment, furniture, and supplies for children in all rooms.

The Facility only provides snacks for the school age children. There is a food preparation area in Pod "D" and Pod "E" with a refrigerator, sink with hot/cold running water, and microwave. Disposables dishes and utensils are used to serve snacks to the school age children. The Facility has trash cans with tight fitting lids in all rooms.

The program will utilize the elementary school playground which has an age appropriate climbing structure with sufficient resilient materials. Shade is provided by trees and building overhangs. Drinking water will be provided via a combination of water coolers/disposable cups and water fountains indoors and outdoors. There is adequate equipment and supplies for children outdoors. LPA did not observe any bodies of water during today's visit. Transportation is not provided by the Facility.

A fire clearance approval was received from the San Jose Fire Department prior to today's inspection. Exit interview was conducted with Anjelica Del Toro, area manager, and LPA advised Angelica that the Boardroom, Pod "D", and Pod "E" will be added to the existing school age license effective today, August 15, 2022.

Notice of site visit issued 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: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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