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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414559
Report Date: 06/05/2023
Date Signed: 06/05/2023 02:16:04 PM

Document Has Been Signed on 06/05/2023 02:16 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 PRESCHOOL @ ORCHARD ELEMENTARYFACILITY NUMBER:
434414559
ADMINISTRATOR:NICOLE BOTELHOFACILITY TYPE:
850
ADDRESS:921 FOX LANETELEPHONE:
(408) 944-0395
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 42TOTAL ENROLLED CHILDREN: 30CENSUS: 15DATE:
06/05/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Nicole BotelhoTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mel Matos conducted an unannounced case management inspection to discuss the lead water testing and Action Level Exceedance (ALE) for one water outlet within the Facility. LPAs met with Nicole Botelho, director, and explained purpose of today's inspection to her.

The lead testing was completed by Forensic Analytical Consulting Services on March 31, 2023. An Action Exceedance Level is a value of 5.5 parts per billion or greater. One water outlet (water faucet) - Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion.

Nicole states that the one water faucet was removed from service and drinking water is being provided only from drinking fountains that tested below the ALE value of 5.5 parts per billion. Nicole states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested.

The Self-Certification form (LIC 9275), Sampling Checklist form (LIC 9276) and updated Facility Sketch (LIC 999) were provided to LPA Matos prior to today's inspection.

Exit interview conducted and report was reviewed with the Director, Nicole Botelho. The following Type B deficiency is cited on the attached page (LIC 809-D). Copy of appeal rights was provided to Nicole prior to the conclusion of today's inspection.

Notice of site visit was issued and must remain posted for 30 days.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023
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
Document Has Been Signed on 06/05/2023 02:16 PM - It Cannot Be Edited


Created By: Melvin S Matos On 06/05/2023 at 01:08 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 PRESCHOOL @ ORCHARD ELEMENTARY
FACILITY NUMBER: 434414559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2023
Section Cited

101700.3(b)(1)

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Lead Testing Written Directives (b)(1) a result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
This requirement was not met as evidenced by:
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Director states that the water faucet was removed from service and drinking water was provided only from drinking fountains that have tested below the ALE value of 5.5 parts per billion.
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Fixture D (space between Rooms 1 & 2 - Art Room) reported an ALE of 24.9 parts per billion.
This poses a potential risk to the health, safety, and personal rights of children in care.
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Director states that the water faucet was recently replaced and that the Facility is in the process of getting the faucet retested. Nicole agreed to submit results of follow up lead testing to LPA by 07/05/23.

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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:Diana Stephenson
LICENSING EVALUATOR NAME:Melvin S Matos
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023


LIC809 (FAS) - (06/04)
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