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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414659
Report Date: 07/28/2022
Date Signed: 07/28/2022 12:43:59 PM


Document Has Been Signed on 07/28/2022 12:43 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:
07/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Destiny MurilloTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) James Santos conducted an Unannounced Case Management visit at the facility today. LPA met with Director, Destiny Murillo and discussed the purpose of the visit which was to review a self reported incident that occurred on 7/19/22 involving two children where one of the child (C2) asked the other child (C1) to reveal himself. Per report, there was no physical contact or injuries occurred. The incident was reported by the Director to CCL on 7/20/22.

Per today's interview with the Director, the incident allegedly happened during snack time around 4pm. Director stated there were 12 children during that time of that day. They were all outside by the table area and there were 3 teachers present. Per Director, the teachers did not witness any incident with the children. Director stated they were only notified about the incident by one of the parents through email on 7/19 at 9:12pm. Director spoke with both children's parents the following day, 7/20 about the incident. As a result of the facility's review, one of the child (C2) no longer attends the school.

During today's visit, LPA interviewed the teachers that were present that time. Per interviews with the teachers, they did not witness any incident with the children.
LPA also interviewed the child (C1) but was not able to provide any information about the incident.

The area the incident and the lines of sight of the teachers were evaluated, no regulatory violations were cited based on the information gathered. LPA also obtained facility documentation during today's visit.

No deficiencies cited. Exit interview conducted and report was reviewed and a copy given to the Director.


NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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