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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414659
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:01:34 PM


Document Has Been Signed on 07/21/2022 03:01 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 ELEMENTARYFACILITY NUMBER:
434414659
ADMINISTRATOR:GLORIA LEWISFACILITY TYPE:
840
ADDRESS:1755 GILDA WAYTELEPHONE:
(408) 821-5015
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:110CENSUS: 19DATE:
07/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Destiny MurilloTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), James Santos conducted an unannounced case management visit today and met with Director, Destiny Murillo. The purpose of the visit was in regards to an incident reported to the Department involving a child who is 4 years old. Per the school's license, they are licensed to serve ages 5-12 years old. As a result, the school was out of the scope of their license.

During today's visit, LPA reviewed the child's record. Per record review, the child was born in January 2018 which makes the child 4 years and 6mos.

As a result of the case management inspection, a deficiency has been cited. See LIC809D page for deficiency.

Exit interview conducted and report was reviewed with Director, Destiny Murillo. A copy of this report and appeals right were provided to Director as well.


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.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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 07/21/2022 03:01 PM - It Cannot Be Edited

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: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2022
Section Cited

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Limitations on Capacity:
A licensee shall not operate a child care center beyond the conditions and limitations specified on the license,including the capacity limitation.

This requirement is not met as evidence by:
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A child who is 4 years and 6 months old is currently enrolled in the school. However, the school is licensed to serve ages 5-12 years old. This poses a potential health, safety or personal rights risk to persons 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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2