<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414659
Report Date: 07/17/2019
Date Signed: 07/17/2019 12:14:02 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 @ NODDIN ELEMENTARYFACILITY NUMBER:
434414659
ADMINISTRATOR:GLORIA LEWISFACILITY TYPE:
840
ADDRESS:1755 GILDA WAYTELEPHONE:
(408) 307-7834
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:110CENSUS: 28DATE:
07/17/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gloria LewisTIME COMPLETED:
12:30 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) 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 finish reviewing a self reported incident that occurred at the facility on 05/23/19 involving a child falling off of a playground structure. LPA did not complete the review of the inspection on 6/26/19 due to the center leaving for a scheduled field trip.

LPA reviewed records and 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 no additional investigation is necessary.

Deficiency cited on the following page. $200.00 civil penalty assessed. Appeal rights printed and reviewed.

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: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
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 2
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: 07/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2019
Section Cited
CCR
101170(e)(2)
1
2
3
4
5
6
7
Criminal Record Clearance. Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline.
1
2
3
4
5
6
7
The criminal background transfer and government issued ID for two staff members was sent to CCL. The individuals have been associated. Deficiency has been cleared.

$200.00 civil penalty assessed today.
8
9
10
11
12
13
14
This requirement was not met as evidenced by two teachers fingerprint cleared but, not associated to the facility. This poses a potential risk to the Health, Safety or Personal Rights to children in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2