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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000839
Report Date: 10/10/2025
Date Signed: 10/10/2025 01:10:31 PM

Document Has Been Signed on 10/10/2025 01:10 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: 0DATE:
10/10/2025
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Spencer Graham and Noel Trevisan TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 10/10/2025, at 11:30 AM, Licensing Program Analysts (LPAs) Wadhwa and Ly arrived at the facility to conduct an unannounced, case management inspection for an increase of capacity.

LPAs met with Lead Teacher, Spencer Graham and explained the purpose of the visit. Between noon and 12:30 PM, the Site Director and two staff arrived at the facility. There were no children present during today’s visit. The program currently operates Monday through Friday 7:00 AM to 8:00 AM and 1:00 PM to 6:00 PM.

The facility is currently licensed to serve 75 children in Portables #19 and #20, the School Library and the Multi-Purpose Room. The program, however, is being currently run in Portable # 20 and the Multi-Purpose Room. The facility has requested an increase of capacity from 75 to 120 students. Fire clearance was obtained on 10/2/2025.

The school age program is exempt from requirements for indoor and outdoor space square footage, fencing, and toilet/sink ratios. No measurements were taken during the inspection.

LPAs inspected Portable #20 and Multipurpose Room for health and safety hazards. Portable #20 is divided into two classrooms: Room #1 and Room #2. Room#1 is designated for use by students in 1st & 2nd grade. Room #2 is designated for use by students in TK & Kindergarten. The Multi-purpose Room is designated for use by students in 3rd through 5th grade.

LPAs observed both rooms in Portable #20 to have their own separate restrooms. The students in the Multipurpose Room use the school restroom located by the entrance of the playground. LPAs observed restrooms to be clean and in proper condition. Restrooms allow for individual privacy.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2025
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: 10/10/2025
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LPAs observed a fire extinguisher located inside of each classroom and one in the Multi-purpose Room. LPAs observed multiple working smoke and carbon monoxide detectors. LPAs confirmed that Portable #20 and the Multi-purpose Room are equipped with the school district fire alarm system.

LPAs inspected Portable #20 and the Multipurpose Room for health and safety hazards.
LPAs observed all rooms to be clean, equipped with age-appropriate activities, materials and furniture. LPAs observed furniture to be in good repair and free of any hazards. The facility ensures solutions, poisons, and other chemicals that are dangerous to children are stored inaccessible to the children in care.

Based on fire clearance approval and LPA inspection, on this day, LPAs Wadhwa and Ly have approved the requested capacity increase from 75 to 120 students.

The program currently uses the playground in front of Portable #20. LPAs inspected the outdoor play area and observed it to be in good repair.

The program uses paper sign in/sign out sheets, and children are signed into the program by the Champions staff. The children are signed out by their authorized representatives with written signatures. LPAs observed licensing posters and required documents to be properly posted.

Supervisors are aware enrolled children using the playgrounds will always be supervised and monitored. LPAs did not observe any pools, spas or bodies of water on school district site.

Supervisor was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days . Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Site Director, Noel Trevisan. A copy of this report was provided to the Site Director. Site Director's signature confirms receipts of this report.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
LIC809 (FAS) - (06/04)
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