434414659-9-15-2022-07-CC-JGSS-CJAUUL-20220915155343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414659
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:54:05 PM

Document Has Been Signed on 09/15/2022 03:54 PM - 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 @ NODDIN ELEMENTARY		FACILITY NUMBER:	434414659
ADMINISTRATOR:	GLORIA LEWIS		FACILITY TYPE:	840
ADDRESS:	1755 GILDA WAY		TELEPHONE:	(408) 821-5015
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY: 110	TOTAL ENROLLED CHILDREN: 110	CENSUS: 25	DATE:	09/15/2022
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Destiny Murillo		TIME COMPLETED:	04:10 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), James Santos arrived at the facility today to conduct the continuation of the Annual inspection. LPA met with Director, Destiny Murillo. LPA reviewed ten (10) children's files. Children's records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, Parent Rights Notice and Personal Rights Notice, LPA reviewed five (5) staff files. Staff records reviewed include Criminal Record Clearance, Immunization Record, CPR/First Aid, Qualifications and Education. LPA advised Licensee of the required "mandated reporter" training for Assembly Bill, AB 1207 requirement for Child Care Providers that all staff must complete and renew every two (2) years. The website for the online training is: http://www.mandatedreporterca.com. Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. As a result of this inspection, deficiencies have been cited. See LIC809D for deficiencies. Exit interview conducted and report was reviewed and a copy was provided to Director. Appeals right reviewed and was also provided to Director. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: James G Santos
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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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Document Has Been Signed on 09/15/2022 03:54 PM - It Cannot Be Edited

Created By: James G Santos On 09/15/2022 at 03:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101174(d)(2)

Disaster and Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview,the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Per Director, they do not have documentions of the drills conducted.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Director agreed to conduct and document an emergency disaster drill and will provide a copy of the drill log to CCL by POC date, 10/14/2022.

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Per review of record, one staff does not have immunization record.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Per Director, the staff will obtain immunization and will send copy of immunization record to CCL by POC date, 10/14/2022.

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:

Joel Segura

LICENSING EVALUATOR NAME:

James G Santos

LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/15/2022 03:54 PM - It Cannot Be Edited

Created By: James G Santos On 09/15/2022 at 03:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Per review of record, one staff has not completed the mandated reporter training.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Per Director, the staff will complete the mandated reporter training and will send copy of certificate to CCL by POC date, 10/14/2022.

Type B

Section Cited

CCR

101216(g)(2)

Personnel Requirements

(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Per review of record, one staff does not have health screening report.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Per Director, the staff will obtain health sreening report (LIC503) and will send copy of report to CCL by POC date, 10/14/2022.

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:

Joel Segura

LICENSING EVALUATOR NAME:

James G Santos

LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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