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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414000839
Report Date: 09/15/2025
Date Signed: 09/15/2025 05:07:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/29/2025 and conducted by Evaluator Ruhi Wadhwa
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20250829093026
FACILITY NAME:CHAMPIONS-JOHN MUIR ELEMENTARY (SA)FACILITY NUMBER:
414000839
ADMINISTRATOR:TREVISAN, NOELFACILITY TYPE:
840
ADDRESS:130 CAMBRIDGE LANETELEPHONE:
(650) 797-4310
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:75CENSUS: 76DATE:
09/15/2025
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Noel Trevisan TIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Lack of supervision resulting in daycare children running out of the classroom.
INVESTIGATION FINDINGS:
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On 9/15/2025 at 2:05PM, Licensing Program Analysts (LPAs) Wadhwa and Garcia conducted unannounced complaint inspection. LPAs met with Director, Noel Trevisan and explained the purpose of the visit. Present during today's inspection were Director, 6 staff, and 76 school-age children. Facility was inspected for health and safety hazards.

During today’s visit, LPAs observed three different instances where children were left unsupervised. One instance was a child running away from the classroom and the other two instances were children were found outside the classroom loitering on the ramp. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED.

Based on today’s inspection, a Type A violation has been issued for lack of supervision in accordance with the Title 22 Division 12 of California Code of Regulations. See LIC 809D.
LPAs informed Director, Noel Trevisan that this report dated 9/15/2025 documenting Type A citation(s) shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care.

Continued on Page 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Ruhi Wadhwa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 05-CC-20250829093026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2025
Section Cited
CCR
101229(a)(1)
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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1) No child(ren) shall be left without the supervision...
This requirement was not met as evidenced by..
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Director will provide a written POC by POC due date 9/16/2025 documenting corrective actions undertaken by the facility to ensure supervision is continious. The written POC will include but not be limited to actions undertaken such as immediate changes in supervision protocols, trainings conducted with staff, reorganization of backpack storage area to ensure minimization of instances where children are required to step outside the classroom.
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Based on LPAs observations on this day, there were three instances recorded at 2:22 PM, 3:09 PM and 3:55 PM when children were observed to be outside of the classroom without active visual supervision, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Ruhi Wadhwa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 05-CC-20250829093026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/15/2025
NARRATIVE
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Also, LPAs informed the Director, Noel Trevisan to provide a copy of this licensing report (9/15/2025) that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed acknowledgement of receipt of Licensing Report (LIC9224), or other written statement, must be placed in the child’s file for verification.

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.

Director was advised Notice of Site Visit to remain posted for 30 days.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Ruhi Wadhwa
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3