<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000839
Report Date: 02/09/2026
Date Signed: 02/09/2026 05:44:07 PM

Document Has Been Signed on 02/09/2026 05:44 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: 73DATE:
02/09/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Site Supervisor of Champions @Portolla, Hind HasanTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On February 9th, 2026 at approximately 1:40pm, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced plan of correction (POC) visit. LPA met with Site Supervisor of Champions @Portolla, Hind Hasan, and explained the purpose of the visit. Present during visit are Site Supervisor, three champion staff and 4 child care career subs supervising a total of 73 school age children.

On February 5th, 2026, LPA conducted an unannounced Case Management deficiencies inspection to facility. During inspection, LPA cited the following citations: Type A citation with civil penalties due to the three individual Champion staff that were not associated to the facility; Type A citation with civil penalties due to the staff not meeting child to teacher ratio (2 aides with 31 school age children); Type B citation for facility not having a site director on site or designated; and Type B citation for aides working without the direct supervision of fully qualified staff. A plan of correction for each citation was created and discussed with Site Supervisor, Hind Hasan.

On 2/06/26, LPA Tapia-Mandujano received an email with the corrections that were asked to be submitted to the office. LPA reviewed documentation received and found that some of the required documentation was not fully received.

While at the facility LPA received LIC 9182, Transfer Request Form of three champion staff to be associated to this facility. During visit, LPA was able to support to associate the staff with this facility. Type A citation will be cleared.

LPA counted all children and teachers to ensure that each classroom is meeting the appropriate teacher to child ratio. Written plan of correction was received and reviewed. Type A citation has been cleared.

Continued on Page 2...

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2026
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
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: 02/09/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2 Continued...

LPA received LIC 308, Designation of Facility for a staff member that has not been present. Plan of Correction required LIC 308 for acting site supervisor and back up in absence of site supervisor. Due to not receiving appropriate documentation it will result in a failure to correct citation with civil penalties.

During today’s visit, LPA observed the Notice of Site Visit to be posted. Per interview and observation, report containing the Type A citations were not posted and the Acknowledgement of Receipt of Licensing Report have not been given to parents until today, 2/09/26. Type B citation will be issued.

LPA Tapia-Mandujano informed Site Supervisor, Hind Hasan that this report dated 2/09/26 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 2/09/26 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.

Office meeting will be scheduled at a later date.

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: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/09/2026 05:44 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 02/09/2026 at 04:35 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: 02/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2026
Section Cited
CCR
101215.1(b)

1
2
3
4
5
6
7
01215.1:Child Care Center Directors Qualifications and Duties: (b) "All child care centers shall have a director."

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
LPA received information for an individual that is not on site.

Written plan on who will be present until a permanent director is hired must be submitted by 2/10/26.
8
9
10
11
12
13
14
Based on observation, interview, and record review, the facility did not comply as the facility has yet to send the appropriate documentation to prove who is the acting director until one is permanently hired. This poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Proof must include LIC 308 for acting director and staff who will substitute during director’s absence. All documentation must be submitted by 2/10/26 to the San Bruno Regional Office.
This is a failure to correct citation. Civil penalties will be assessed.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 02/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/09/2026 05:44 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 02/09/2026 at 04:42 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: 02/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2026
Section Cited
HSC
1596.8595(a)(1)

1
2
3
4
5
6
7
1596.8595(a): "a)(1) Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility visit...that results in a citation for a violation that...immediate risk to the health, safety, or personal rights of children in care. The licensing report provided by the department shall be posted immediately upon receipt, adjacent to the postings required... and on, or immediately adjacent to, the interior side of the main door to the facility and shall remain posted for 30 consecutive days."

This requirement is not met as evidence by:
1
2
3
4
5
6
7
LPA printed another Licensing report from 2/05/25 to be posted immediately.



Civil penalties were assessed for not having this report posted.
8
9
10
11
12
13
14
Based on observation, interview, and record review, the facility did not comply as the facility did not have the report that documents a Type A citation posted. This poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
02/10/2026
Section Cited
HSC1596.8595(c)(1)(3)

1
2
3
4
5
6
7
1596.8595(c)(1)(3): "(c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation... (3) The licensee shall require each recipient of the licensing report described in paragraph (1) pertaining to a complaint investigation to sign a statement indicating that he or she has received the document and the date it was received."
This requirement is not met as evidence by:
1
2
3
4
5
6
7
LPA observed that parents were being provided the LIC 9224 to sign upon pick up.

Upon next inspection, LPA will review to ensure each child enrolled has this form in their file.
8
9
10
11
12
13
14
Based on observation, interview, and record review, the facility did not comply as the facility did not start to give the LIC 9224 to parents until today. This poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 02/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2026


LIC809 (FAS) - (06/04)
Page: 5 of 5