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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000839
Report Date: 02/05/2026
Date Signed: 02/05/2026 06:13:19 PM

Document Has Been Signed on 02/05/2026 06:13 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: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 85DATE:
02/05/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Site Supervisor from Champions at Potola, Hind HasanTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On February 5th, 2026 at approximately 1:45pm, Licensing Program Analyst (LPA) Tapia-Mandujano came to the facility and conducted a case management-deficiencies inspection. LPA initially met with teacher, Karen Gonzalez and explained the purpose of the visit. Present in the facility are three champion staff with four substitutes through Child Care Careers supervising a total of 85 school-age children. LPA was able to observe that the substitutes were Trustline cleared. LPA observed that the Champions staff were cleared but not associated through Guardian. Type A citation and civil penalties were assessed.

During today's inspection, LPA observed that there is no director on site. Type B citation was issued. At approximately 3:30pm, Site Supervisor from Champions at Potola, Hind Hasan showed up. LPA explained the purpose of the inspection to Hind Hasan.

Upon arrival, LPA asked to look at staff records and facility records to review. Staff on site were unable to provide records to LPA. Site Supervisor was able to show records to LPA through her phone. LPA reminded Site Supervisor, Hind that facility must be able to provide records upon request, failure to provide will result in an immediate citation.

During today's inspection, there is only one fully qualified staff that is in the multi-purpose room, and the rest of the staff present either have no units or not have full qualifications. LPA observed that in Portable 19 (split into two classrooms) were being led by teacher aides without the direct supervision of a fully qualified teacher. Type B citation was issued.

During physical plant inspection, LPA counted children to ensure ratio is being met and LPA found that that there was one classroom with 31 school age children with two teacher aides. This is a repeated violation Type A citation and civil penalties were assessed.

Continued on Page 2...

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2026
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 5
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)
Page: 2 of 5
Document Has Been Signed on 02/05/2026 06:13 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 02/05/2026 at 02:51 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: 02/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2026
Section Cited
CCR
101215.1(b)

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101215.1:Child Care Center Directors Qualifications and Duties: (b) All child care centers shall have a director.

This requirement is not met as evidenced by:
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During inspection at approximately 3:30pm, Site Director from Champions at Portola showed up.
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Based on observation, interview, and record review, the facility did not comply as the facility does not have a director for this facility as of January 23rd, 2026. This poses a potential health, safety or personal rights risk to persons in care.
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Facility must submit proof of fully qualified director to the department by 2/06/26. Proof must include LIC 308 for acting director and staff who will substitute during director’s absence.
Facility must submit by 2/06/26 to the San Bruno Regional office.
Type B
02/13/2026
Section Cited
CCR101216.2(e)

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101216.2:Teacher Aide Qualifications and Duties:(e)An aide shall work only under the direct supervision of a teacher.

This requirement is not met as evidenced by:
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Effective immediately, facility must ensure that the aides are not left in charge of the classrooms without a fully qualified teacher with them.
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Based on observation, interview, and record review, the facility did not comply as the facility has aides working without the direct supervision of a fully qualified staff. LPA observed there are two classrooms where there were only aides supervising the children. This poses a potential l health, safety or personal rights risk to persons in care.
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Facility must submit a written plan on how they will ensure that aides are working under the direct supervision of a fully qualified teacher.

Written plan must be submitted to the deparmtent by 2/13/26.
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:
Leslit Tapia-Mandujano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/05/2026 06:13 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 02/05/2026 at 04:00 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: 02/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2026
Section Cited
CCR
101516.5(b)(1)

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101516.5: Teacher-Child Ratio:" (b) There shall be a staffing ratio of one teacher and one aide present to every 28 children in attendance.(1) A teacher shall supervise no more than 14 children or with an aide a maximum of 28 children."

This requirement is not met as evidenced by:
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Facility must submit a written plan on how they plan to maintain teacher to child ratio at all times.

Facility must submit this written plan by 2/06/26 to the San Bruno Regional office.
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Based on observation and interviews, the facility did not comply with the section cited above as LPA observed that there were 31 school age children with two teacher aides without the supervision of a qualified staff. This poses an immediate health, safety or personal rights risk to persons in care.
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Facility must also have a training/meeting with all staff of what actions to take when they are about to go over teacher to child ratio.

This is a repeated violation. Civil penalties were assessed.
Type A
02/06/2026
Section Cited
CCR101216(i)(2)

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101216 Personnel Requirements: "(i) Prior to employment or initial presence in the child care center, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance...:

This requirement is not met as evidenced by:
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Facility must submit a transfer request form to associate the three staff that are cleared but not assocaited to the facility.

Facility must submit this form by 2/06/26 to the San Bruno Regional office.
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Based on observation, interview, and record review, the facility did not comply as there are three champion teachers that are not associated to this site. This poses an immediate health, safety or personal rights risk to persons in care.
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Facility must also submit a written plan on how they will ensure that all staff are cleared and associated to the facility prior to being present on site by 2/06/26 to the San Bruno Regional Office.

Civil penalties were assessed.
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:
Leslit Tapia-Mandujano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 02/05/2026
NARRATIVE
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Page 2 Continued...

LPA Tapia-Mandujano informed Site Supervisor, Hind Hasan that this report dated 2/05/26 documents two Type A citations which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

Also, LPA Tapia-Mandujano informed Site Supervisor, Hind Hasan to provide a copy of this licensing report dated 2/05/26 that documents any Type A citations 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 (LIC 9224), or other written statement, must be placed in the child's file for verification.

An office meeting may be scheduled.

Deficiencies were cited today under Title 22 Division 12 of the Ca. Code of Regulations.

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

Exit interview conducted and report was reviewed with Site Supervisor, Hind Hasan.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
LIC809 (FAS) - (06/04)
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