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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000839
Report Date: 01/06/2025
Date Signed: 01/06/2025 03:35:49 PM

Document Has Been Signed on 01/06/2025 03:35 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CHAMPIONS-JOHN MUIR ELEMENTARY (SA)FACILITY NUMBER:
414000839
ADMINISTRATOR/
DIRECTOR:		TREVISAN, NOELFACILITY TYPE:
840
ADDRESS:130 CAMBRIDGE LANETELEPHONE:
(650) 797-4310
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 75TOTAL ENROLLED CHILDREN: 75CENSUS: 32DATE:
01/06/2025
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 AM
MET WITH:Director, Noel TrevisanTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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On January 6, 2025, at approximately 1:30 PM, Licensing Program Analyst (LPA) Melissa Zaragoza conducted an unannounced, annual inspection. LPA met with the director, Noel Trevisan, and explained the purpose of the visit.

Champions John Muir is a school age program. School age program is located in John Muir Elementary School. School age program operates in one classroom, in Portable #20. Portable #20 has 2 rooms inside.

Hours of operation are Monday through Friday 7:00am to 8:00am and 2:00pm to 6:00pm. Present during LPA's visit was the director, 32 school age children and 3 teachers. Program is operating within capacity limits and ratio during LPA's visit.

LPA inspected facility, indoors and outdoors, for health and safety hazards. Classrooms includes a variety of toys and materials that were in good condition. LPA observed classroom to have age-appropriate furniture, equipment, and materials. LPA observed cleaning materials to be stored in high shelves, inaccessible to children in care.

Per director, children do not sleep while they are in the program. During visit LPA observe classroom to have trash cans inside the classroom with tight fitted lids. LPA observed children’s backpacks to be hooked outside of portable classroom.

The classrooms are equipped with a fully charged fire extinguisher and first aid kit. LPA observed Carbon monoxide detector and smoke detector in the classroom. Carbon monoxide detectors were tested during visit and were observed to be working.

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAMPIONS-JOHN MUIR ELEMENTARY (SA)
FACILITY NUMBER: 414000839
VISIT DATE: 01/06/2025
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There is one bathroom in each classroom for the children to use. Bathrooms for children were observed to be clean. Bathrooms located inside room 1 has 1 toilet stall and 1 sink. Bathroom located inside room 2 has 2 toilet stalls and 2 sinks. The sinks and toilet were in working condition. Bathroom was equipped with appropriate sanitation products. LPA observed bathroom to have trash can bins with tight fighting lids. LPA observed no cleaning solutions, poisons, and other hazardous materials for to be stored in bathroom. LPA did not observe any accessible poisons or chemicals in classroom.

Program provides snacks only. Per director, children bring water bottles from home and refill them in the classroom. Per director, children refile their water bottle with a water filter. Outdoor area is entirely enclosed and fenced. LPA observed outdoor play area to have natural shade. LPA observed play structure to have tanbark flooring. LPA observed play structure and materials to be in good conditions.

Program uses a form for parents to sign in and out for their sign in/sign out system. Children were properly signed in during LPAs’ visit. LPA observed licensing posters and required documents to be properly posted inside the classroom. Program’s last disaster drills was conducted on November, 2024.

LPA reviewed 6 facility staff records. LPA reviewed 6 random children facility records which were complete and had all required documents. Children's records have emergency information on file. Multiple staff on site have a current CPR/First Aid certification. LPA reminded director, mandated reporter training must be renewed every 2 years for all staff working with children. Staff records also include required immunizations that were made available for review.

Director was reminded all staff hired are required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

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

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAMPIONS-JOHN MUIR ELEMENTARY (SA)
FACILITY NUMBER: 414000839
VISIT DATE: 01/06/2025
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Director 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.

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.

Facility has not tested for lead water.

LPA's discussed the safe sleep regulations with director and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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-care-centers/.

Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Program was cited a Type B citation for not testing for lead water.

Please see LIC 809-D for deficiencies cited today. Appeal rights were given to the director.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the director, Noel Trevisan.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/06/2025 03:35 PM - It Cannot Be Edited


Created By: Melissa Zaragoza On 01/06/2025 at 03:20 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHAMPIONS-JOHN MUIR ELEMENTARY (SA)
FACILITY NUMBER: 414000839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with the director, the licensee did not comply with the section cited above by not testing for lead water, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Per director, they plan to test for lead water as soon as possible.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
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