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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841006
Report Date: 03/21/2024
Date Signed: 03/21/2024 05:21:06 PM

Document Has Been Signed on 03/21/2024 05:21 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CHAMPIONS AT MILLER MIDDLE SCHOOLFACILITY NUMBER:
334841006
ADMINISTRATOR:DORA VELASQUEZFACILITY TYPE:
840
ADDRESS:17925 KRAMERIA AVENUETELEPHONE:
(951) 789-8181
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 112TOTAL ENROLLED CHILDREN: 112CENSUS: 4DATE:
03/21/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Sadura PattonTIME COMPLETED:
05:25 PM
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A required – 3 year inspection is being conducted as part of a compliance review. Licensing Program Analyst (LPA) Giselle Carbullido toured the school-age center, inside and out. The following was observed:

Days and hours of operation are M, TU, TH, FRi -1:30PM -6PM; Wed. 12- 6PM
The inspection consisted of reviews of the CARE tool domains. The inspection found the facility to be in compliance except as noted on the LIC809D. Deficiencies were cited this visit.
The licensee is asked to update the following documents and submit to licensing within 30 days: (only if changes have been made)
1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule
4. LIC 309 Administrative Organization
5. LIC 308 Designation of Administrative Responsibility
The following items have been posted and are updated where necessary:
License, Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
Parent’s Rights Poster (PUB393), Personal Rights (LIC613A); Child Car Seat Law, Menu
The facility is operating within the terms of the license.
Ratios were met with appropriate supervision during this inspection.
Classrooms are clean, free of hazards and equipped with age-appropriate furniture. See LIC9102 TV technical advisory.
No weapons stored at the facility.
There are no accessible bodies of water present.
Medications are stored inaccessible to children in the file cabinet.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHAMPIONS AT MILLER MIDDLE SCHOOL
FACILITY NUMBER: 334841006
VISIT DATE: 03/21/2024
NARRATIVE
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Licensee [or facility representative] was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Facility Representative, Sadura Patton
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHAMPIONS AT MILLER MIDDLE SCHOOL
FACILITY NUMBER: 334841006
VISIT DATE: 03/21/2024
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 CCC DID NOT COMPLETE TESTING PRIOR TO THEIR DEADLINE: Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5- years after the date of the first test. For childcare center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). * Attestation letter on file for bottled water and dispenser for water access.
LPA verified that the lead testing was Not completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. PIN 22-05-CCP Page Four. LPA referred licensee [or facility representative] to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – Requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years.
AB2960 – Childcare and development services, online portal – Effective June 20, 2022 - This bill requires the State Superintendent of Public Instruction (SSPI), within the California Department of Education (CDE), to develop and post on CDE's website a comprehensive child care and development services online portal for families and providers by June 30, 2022.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHAMPIONS AT MILLER MIDDLE SCHOOL
FACILITY NUMBER: 334841006
VISIT DATE: 03/21/2024
NARRATIVE
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Hazards and other items that are dangerous are stored inaccessible to children. See LIC9102TA Poisons and toxins are locked.
All floors are clean and safe.
Bathrooms were observed to be safe, sanitary and in operating condition.
Outdoor activity areas are enclosed by appropriate fences, free of hazards and supplied with age and size appropriate equipment in good condition.
Food preparation area is clean, free of litter, rodents, and other vermin.
Measures are taken to keep the facility free of flies, other insects,and rodents. Food is stored appropriately and protected from contamination. Storage containers for solid waste, including moveable bins-have tight-fitting covers in good repair. See LIC9102TV Menus are current and posted in a place visible by the child’s authorized representative, dated and made available upon request. Uncontaminated drinking water is readily available both indoors and outdoors and provided by Yes Areas around or under high climbing equipment have cushioned with material that absorbs a fall: Yes Sign in/Sign out record was reviewed and meets regulation requirements: Yes Opening and closing staff member’s CPR/First Aid expires on SP 08/24 Director completed Health and Safety Training See LIC9102 TV Staff files were reviewed and are complete:No LIC 809D for deficiency cited. Staff have received on the job training for housekeeping, sanitation and universal health precautions. Children files are complete. No See LIC 809D for deficiencies cited. Fire & earthquake drills are conducted and documented every six months. Yes Last drill: 10/23 Facility Representative was informed the Department has inspection authority per Health and Safety Codes. Facility Representative provided the Unusual Incident Reporting email: UnusualIncidentReportsDO09@dss.ca.gov
To receive important licensed- related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
MyChildCarePlan.org – Centers and Family Child Care Homes Licensee [or facility representative] was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 05:21 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 03/21/2024 at 04:16 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHAMPIONS AT MILLER MIDDLE SCHOOL
FACILITY NUMBER: 334841006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216.1(g)
Teacher Qualifications and Duties
(g) A photocopy of the teacher's Child Development Permit as specified in (c)(3) above, or a photocopy of the teacher's transcript(s) documenting successful completion of required course work, shall be maintained at the center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview) and (record review)], the licensee did not comply with the section cited above in that Director is missing 6 ECE units and administration course which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Facility will submit waiver for missing administration course and submit completed units or degrees, or enrollment for additional educational units to the department by POC due date 03/25/24.
Type B
Section Cited
CCR
101221(b)
Child's Records
(b) Each record shall contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in that C2 is missing LIC702, LIC700, LIC995 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Facility will submit LIC995, LIC700 and LIC 702 for C2 to the department by POC due date 03/25/24 or earlier.
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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 05:21 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 03/21/2024 at 04:16 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHAMPIONS AT MILLER MIDDLE SCHOOL
FACILITY NUMBER: 334841006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review , the licensee did not comply with the section cited above in C2 is missing LIC627 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Facility will submit LIC 627 for C2 to the department by POC due date 03/25/24 or earlier.
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview) and (record review)], the licensee did not comply with the section cited above in that C2 is missing LIC613A which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Facility will submit LIC613A for C2 to the department by POC due date 03/25/24 or earlier.
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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


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