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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001497
Report Date: 02/27/2025
Date Signed: 02/27/2025 02:54:08 PM

Document Has Been Signed on 02/27/2025 02:54 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 AT PORTOLAFACILITY NUMBER:
414001497
ADMINISTRATOR/
DIRECTOR:		HASAN, HINDFACILITY TYPE:
840
ADDRESS:300 AMADOR AVE., ROOM #1TELEPHONE:
(650) 440-1371
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 42TOTAL ENROLLED CHILDREN: 42CENSUS: 19DATE:
02/27/2025
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Site Director, Hasan HindTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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On 02/27/2025, at approximately 1:20PM, Licensing Program Analyst (LPA) Melissa Zaragoza conducted an unannounced case management visit regarding an Action Level Exceedance (ALE) due to lead in the Child Care Center's water. LPA was granted entry to the facility by the site director, Hind Hasan, LPA explained the purpose of the visit. Present during the visit were 2 staff and 19 children. The facility is in compliance with staff-child ratios.

LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires the Lead Testing of water in the Child Care Center with the site director, during the inspection. All Child Care Centers that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing. The facility initially tested its water for lead on 01/10/2025 and was not in compliance with the testing requirement.

The facility received the initial ALE report from the Vendor on 02/05/2025. Test results for two fixtures in this facility exceeded a higher level of parts per billion (ppb) allowed, 5.5 ppb, fixture C (11.0) and fixture E (9.5). Fixtures C and E are located inside the cafeteria building. Cafeteria is located in an off-limit area to children. Per director, Brittany Beck, cafeteria is not a licensed room, and the facility does not use it for food preparation or drinking water. LPA observed faucets C and E inaccessible to children. Per director, the facility plans to fix the exceedance, by discuss a plan of correction with the Champion’s administrator. Per site director, the facility uses water from the inside the classroom, a water filtered, water pitcher. All other fixtures tested below the threshold and are in compliance with the Written Directives detailed in PIN 21-21.1-CCP.

Per Written Directives 101700.3(b)(2), licensees shall maintain a lead value at or below 5ppb in all outlets subject to testing requirements for the health and safety of children in care. Due to updated guidance on the written directives in PIN 21-21.1-CCP, the facility will be cited for the ALE of fixture C and E.

Please see LIC809-D for deficiency cited and cleared today.

Appeal Rights were provided.

This report was reviewed and signed by the site director, Hind Hasan.

A Notice of Site Visit was given and must be posted for 30 days.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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 2
Document Has Been Signed on 02/27/2025 02:54 PM - It Cannot Be Edited


Created By: Melissa Zaragoza On 02/27/2025 at 02:34 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 AT PORTOLA
FACILITY NUMBER: 414001497

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2025
Section Cited

101700.3

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101700.3 California Lead Action Level at Child Care Centers (b)(1) A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.

This requirement was not met as evidenced by:
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The facility plans to fix the lead water exceeded fixture by discusing a plan with the Champion's administrator and updating the LPA of plan of correction, for faucets.
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Based on results received from the certified water samplers, the facility exceeded 5.5 ppb of lead in their water source. This pose a potential health, safety, or personal rights risk to persons in care.
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Type B
03/27/2025
Section Cited
HSC159.16(a)(1)

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HSC 159.16(a)(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
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Facility tested water fixtures January 10, 2025, after the lead testing requirement due date. Deficiency cleared during visit.
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Based on observation and record review, the licensee did not comply with the section cited above by not completing lead testing by January 1, 2023 which poses a potential 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.
SUPERVISOR'S NAME:Marie Rodriguez
LICENSING EVALUATOR NAME:Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
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