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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414659
Report Date: 05/06/2019
Date Signed: 05/06/2019 09:32:14 AM

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 @ NODDIN ELEMENTARYFACILITY NUMBER:
434414659
ADMINISTRATOR:GLORIA LEWISFACILITY TYPE:
840
ADDRESS:1755 GILDA WAYTELEPHONE:
(408) 307-7834
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:110CENSUS: 12DATE:
05/06/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Biana MaduenoTIME COMPLETED:
09:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Rangel met with teachers Bianca Madueno, Kalaya Payne-Alex and director Gloria Lewis for a case management inspection to amend a deficiency that was incorrectly recorded and never issued or signed with a visit date of 2/15/19. During today's inspection, LPA also viewed one teacher without current CPR/1st aid certification, alone with children in the morning.

Deficiency issued. Appeal rights printed and reviewed.

Notice of site visit issued and shall remain posted for 30 days.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2019
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 @ NODDIN ELEMENTARY
FACILITY NUMBER: 434414659
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2019
Section Cited
CCR
101216(f)
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Personnel Requirements:
At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities. This requirement was not met as evidenced by LPA viewing one staff member without current CPR/1st aid certifcations alone in the facility for up to 30 minutes with children.
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Licensee shall review regulations, and submit a letter of understanding outlining how this will be avoided in the future by the POC date.
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This poses a potential risk Health, Safety Personal Rights risk to 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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2019
LIC809 (FAS) - (06/04)
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