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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001497
Report Date: 08/27/2025
Date Signed: 08/27/2025 01:26:15 PM

Document Has Been Signed on 08/27/2025 01:26 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: 42; 42; 42TOTAL ENROLLED CHILDREN: 135CENSUS: 0DATE:
08/27/2025
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Hind HasanTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 8/27/2025, at 9:00 AM, Licensing Program Analysts (LPAs) Wadhwa and Ly conducted an unannounced, annual inspection and a licensee-initiated case management inspection for increase in capacity and room addition. LPAs met with Site Director, Hind Hisan and explained the purpose of the visit.

The facility operates and an after-school program from Monday through Friday 7:00 AM to 8:00 AM and 1:00 PM to 6:00 PM.

There were two staff (including Site Director) but no students present during today’s inspection. Both staff members present today at the facility are fingerprint cleared.

Facility is currently licensed to serve 42 children in Room #75 & Room #77 of the Portola Elementary School. Facility has requested a change of space to operate out of Room #30, Wing - Happy Land, Wing - Super Scholars, Wing - Leadership Hall and the Multi-Purpose Room and increase capacity from 42 to 90 students. Fire clearance was obtained on 6/24/2025.

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.

Per Site Director, the after school program began on 8/21/2025, and the program was being operated out of Room#30 and Multipurpose room, prior to receiving approval from Licensing. A Type B citation will be issued in accordance with the California Code of Regulations, Title 22, see LIC 809D.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2025
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.

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Document Has Been Signed on 08/27/2025 01:26 PM - It Cannot Be Edited


Created By: Ruhi Wadhwa On 08/27/2025 at 11:50 AM
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: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2025
Plan of Correction
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Site Director will submit a completed Mandater Reporter Training certification for all staff by POC due date 9/10/2025.
Type B
Section Cited
CCR
101212(c)
Reporting Requirements
(c) The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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LPAs advised Site Director that prior to using unapproved spaces, Licensing should be notified so that proper approvals are obtained before use. As of today, the requested room additions have been approved. Deficiency has been cleared today and a letter of Clear Deficiency has been provided to the Site Director.
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:
Ruhi Wadhwa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2025


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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 AT PORTOLA
FACILITY NUMBER: 414001497
VISIT DATE: 08/27/2025
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LPAs inspected Room#30, Wing - Happy Land, Wing - Super Scholars, Wing - Leadership Hall, and the Multipurpose Room for health and safety hazards. LPAs observed a fire extinguisher located inside of all the rooms. LPAs observed a working carbon monoxide detector in Room #30. The Site Director was advised to have the CO detector always plugged in. Facility ensures solutions, poisons, and other chemicals that are dangerous to children are stored inaccessible to the children in care.

LPA observed all the rooms to be added, to be clean and equipped with age-appropriate toys, materials and furniture. LPAs observed furniture to be in good repair. LPAs observed the facility is equipped with school district fire alarm system.

The program has requested the use of the following restrooms: Girls Room 39, Boys Room 11, Girls Room 12, and Boys Room 38. LPAs observed restrooms to be clean and in proper condition. Restrooms allow for individual privacy.

Based on fire clearance approval and LPA inspection, room additions of Room #30, Wing - Happy Land, Wing - Super Scholars, Wing - Leadership Hall and the Multi-Purpose Room are being approved for use as of today: 8/27/2025. On this day, LPAs Wadhwa and Ly have approved the requested capacity increase from 42 to 90 students.

The facility provides dry snacks to kids in the afternoons. Food supplies are received through a single vendor two times a month. The supplies are stored in Main Storage Room #27. Students do not have access to this space. Parents provide a water bottle from home and the facility provides refill as needed through the filtered water station in the Multi-purpose Room.

The entire outdoor area of the school is enclosed by a fence that is at least four feet tall. Facility is currently licensed to use enclosed Outdoor area #1 and Outdoor area #2. LPAs inspected Outdoor Area #2 in the front of the school and found 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.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
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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 AT PORTOLA
FACILITY NUMBER: 414001497
VISIT DATE: 08/27/2025
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LPAs observed licensing posters and required documents to be properly posted. The program’s last disaster drills were conducted in July 2025.

LPAs reviewed children’s facility records which were complete and had all required documents. Children's records have emergency information on file.

LPAs reviewed facility staff records and found some staff to be missing immunizations and other required documents available for review today. Staff was also found to be missing Mandated Reporter Training Certifications. A Type B citation will be issued in accordance with the California Code of Regulations, Title 22, see LIC 809D.

Two staff files did not have LIC 503 available for review today. Advisory Note: A Technical Violation will be issued today See LIC9102.

Director was reminded all staff hired are required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Facility was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

Director 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.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
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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 AT PORTOLA
FACILITY NUMBER: 414001497
VISIT DATE: 08/27/2025
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

This facility intends to provide Incidental Medical Services – IMS. LPAs discussed Incidental Medical Services. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

An exit interview was conducted and Plan of Corrections (POC) were developed and reviewed with the Site Director, Hind Hasan. A copy of this report and appeal rights were discussed and left with the Site Director whose signature on this form confirm receipts of these reports.

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.



NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
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