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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000839
Report Date: 08/04/2025
Date Signed: 08/14/2025 11:36:32 AM

Document Has Been Signed on 08/14/2025 11:36 AM - 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: 30DATE:
08/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:12 AM
MET WITH:Noel TrevisanTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 8/4/2025, at 10:12AM., Licensing Program Analysts (LPAs) Wadhwa and Gomez conducted an unannounced complaint visit and met with the Director, Noel Trevisan. LPAs explained the purpose of the visit. Present during today’s visit were 30 children and 5 staff.

The purpose of this report is case management to cite for deficiencies observed during the complaint inspection visit.

During today’s inspection, LPA reviewed facility records, interviewed staff and performed observations.

At 10:18 AM, based on observation, LPAs confirmed a child went into an empty classroom (Room #1) to use the bathroom, while being unsupervised.
Immediately after, staff followed the child to remind them to ask for permission before using the bathroom. LPA issued advisory note: Technical Violation (LIC9102TV)

At 10:35 AM, based on interviews, LPAs confirmed that the program occasionally uses an unlicensed area notably the open area located behind the portables.

At 1:14 PM, based on record review, staff files (S5 and S6) were found to have incomplete documents specifically the Mandated Reporter Training certification, LIC 9052 and immunizations. LPA issued advisory note: Technical Violation (LIC9102TV).

Continued to Page 2
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/04/2025
NARRATIVE
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Based on today’s inspection, a deficiency were observed according to the Title 22 Division 12 of California Code of Regulations and cited on the 809D. An exit interview was conducted with the Director and a Plan of Correction was discussed. A copy of this report with the appeal rights was provided, and signature of this form acknowledges the receipt of these documents.

Exit interview conducted and report was reviewed with Director, Noel Trevisan.

A copy of the report will be emailed to the Director along with a Notice of Site Visit, that must remain posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 11:36 AM - It Cannot Be Edited


Created By: Ruhi Wadhwa On 08/04/2025 at 12:51 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: 08/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2025
Section Cited
CCR
101212(c)

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101212 Reporting Requirements
(c)The licensee shall notify the Department in writing of his/her intent prior to making any structural changes

This requirement has not been met as evidenced by:
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Director will submit a written statement via email confirming that the facility will no longer use the off-limit, unapproved areas by POC due date of 8/18/2025.
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Based on interviews, LPAs confirmed that the program occasionally uses an unlicensed area notably the open area located behind the portables.
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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.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Ruhi Wadhwa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


LIC809 (FAS) - (06/04)
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