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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414659
Report Date: 06/26/2019
Date Signed: 06/26/2019 10:09:34 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: 30DATE:
06/26/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Gloria LewisTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Stephanie Rangel conducted an Unannounced Case Management- Incident Inspection at the facility today. LPA met with director Gloria Lewis and informed her that the purpose of the inspection is to review a self reported incident that occurred at the facility on 05/23/19 involving a child falling off of a playground structure.

LPA interviewed staff during today's inspection that were present when the incident occurred.

The area the incident occurred and the lines of sight of the teachers were evaluated, no regulatory violations were cited at the time of the inspection. LPA has determined that additional investigation is necessary.

NOTICE OF SITE VISIT WAS ISSUED AND MUST 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: 06/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2019
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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