<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622985
Report Date: 06/29/2021
Date Signed: 06/29/2021 05:56:29 PM

Document Has Been Signed on 06/29/2021 05:56 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CHAMPIONS IRENE B WESTFACILITY NUMBER:
343622985
ADMINISTRATOR:DODGE, AMYFACILITY TYPE:
850
ADDRESS:8625 SERIO WAYTELEPHONE:
(530) 391-6816
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 18TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
06/29/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:28 PM
MET WITH:Leah Cromwell, DirectorTIME COMPLETED:
06:00 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
On 6/29/2021 at 3:28 PM Licensing Program Analyst (LPA) Jeevun Birk-Miller met with Director, Leah Cromwell for the purpose of an unannounced annual random inspection. Director was reminded never to exceed the conditions, limitations and capacity specified on the license. Census included 8 preschoolers being supervised by one staff members during nap time. Facility hours of operation are Monday through Friday from 7:30 AM to 5:30 PM.

LPAs toured the building including all activity and classroom spaces, restrooms, food service, and outdoor play areas. Currently there no children who require medication, but are stored appropriately and are inaccessible to children. Poisons are not kept on premises. Toxic and hazardous items are inaccessible to children. Furniture and equipment are in good condition. Playground equipment and surfaces are free of loose or sharp parts. The floors appeared clean throughout the facility. The food preparation space is free of litter and all food was protected against contamination. LPAs observed that storage containers for solid waste have tight-fitting covers. Program provides morning breakfast snack, snack and afternoon snack. The children bring food from home for lunch. Menus were posted and drinking water was readily available to children both indoors and outdoors. LPAs observed parents are signing in/out properly through the facility sign-in and out binders.

Two staff files and four children's records were reviewed. Each child's file contained an emergency card and pre-admissions health screenings, and immunization's. At least one staff member present today has current Pediatric CPR and First Aid certification (exp. 10/2021). All staff currently employed with the facility have a criminal record clearance, health screening report, and documentation of the educational background, training, and/or experience. LPAs reminded Director that 100% supervision is required at all times, including during nap time. At 4:34 PM while reviewing the two staff files LPA observed that Mandated Report Training certificates were not current. The Director stated she would work on getting the training completed for both staff. Report continues on 809-C

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Jeevun Birk
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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 3
Document Has Been Signed on 06/29/2021 05:56 PM - It Cannot Be Edited


Created By: Jeevun Birk On 06/29/2021 at 05:30 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: CHAMPIONS IRENE B WEST
FACILITY NUMBER: 343622985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2021
Section Cited
HSC
1596.8662(b)(1)

1
2
3
4
5
6
7
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
1
2
3
4
5
6
7
Assistant Director agrees to have staff take the training and have the training completed. Licensee will submit a copy of the completion certificate to licensing by 07/13/21.
8
9
10
11
12
13
14
following the date on which he or she completed the initial mandated reporter training.his requirement is not met as evidenced by: Based on record review of staff files the facility did not ensure that mandated reporter training was completed after it expired for two staff. This poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jeanne Smith
LICENSING EVALUATOR NAME:Jeevun Birk
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: CHAMPIONS IRENE B WEST
FACILITY NUMBER: 343622985
VISIT DATE: 06/29/2021
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
26
27
28
29
30
31
32
There are no firearms or bodies of water on the premises. LPA observed a functional carbon monoxide detector. LPA reviewed the Department's inspection authority and discussed with Director any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within ten working days.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

This facility evaluation report was reviewed and discussed with Director. A Notice of Site Visit was provided and should remain posted for a period of 30 days for parental review. Director was encouraged to the visit the department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining child care centers.



In the areas that were evaluated, the following Type-B deficiencies were cited under California Code of Regulation Title 22. Refer to the 809-D page of this report.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Jeevun Birk
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3