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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414560
Report Date: 06/07/2024
Date Signed: 06/07/2024 02:48:05 PM

Document Has Been Signed on 06/07/2024 02:48 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CHAMPIONS AT ORCHARD ELEMENTARY SCHOOLFACILITY NUMBER:
434414560
ADMINISTRATOR/
DIRECTOR:		LISA BENNETTFACILITY TYPE:
840
ADDRESS:921 FOX LANETELEPHONE:
(408) 624-0534
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY: 60TOTAL ENROLLED CHILDREN: 40CENSUS: 10DATE:
06/07/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Lisa BennettTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Mel Matos met with Lisa Bennett, director, for an unannounced Annual/Random inspection. LPA toured the indoor and outdoor areas of the Facility during today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), menus, and Activity Schedule. Days and hours of operation are Monday through Friday 8:00 AM to 5:00 PM. The school age program is licensed in Rooms P1, Boardroom, POD "D", POD "E", Library, and Multipurpose Room on the campus of Orchard Elementary School. The Facility also has a preschool program (#434414559) that is licensed in Rooms 1, 2 ,& space between Rooms 1 & 2.

LPA reviewed five children's and two staff files (1 director and 1 teacher) during today's inspection. Each child's file reviewed contains the required documents; including the Information and Emergency Information form (LIC 700) and immunization records. All staff files reviewed contain the required documents; including transcripts/verification of experience/immunization records, and Health Screening Report. All staff have current certificates of completion of the Mandated Reporter Training for Child Care Workers on file. Last fire/disaster drill was completed on April 30, 2024. Director has current CPR and First Aid certifications on file. Lisa understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips).

LPA observed nine school age children in Room P1 with Lisa and one teacher. Lisa understands the conditions, limitations, and capacity specifications of the Facility license. Lisa understands that children shall be visually supervised at all times. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in the director’s office area.

LPA observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. The Facility has adequate ventilation, including central air conditioning/heating. Lisa states that the school district staff clean the Facility Monday through Friday in the evenings. Lisa understands that the Facility must be kept free of flies and other insects & rodents. LPA observed that all furniture and equipment is in good condition and safe for the children.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CHAMPIONS AT ORCHARD ELEMENTARY SCHOOL
FACILITY NUMBER: 434414560
VISIT DATE: 06/07/2024
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Drinking water is readily available for the children in the Facility and in the outdoor playground area via filtered water/reusable water bottles. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Lisa states that there are no weapons or firearms on the premises. The Facility has functioning carbon monoxide detectors.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. The Facility only provides snacks to the children. Parents provide lunches for the children. The Facility has trash cans with tight fitting lids for solid waste. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. Lisa states that there are no poisons in the Facility. LPA observed a complete First Aid kit in the Facility, including a touch less thermometer. Lisa understands that smoking is not allowed on the Facility premises.

Lisa states that the Facility does not administer any medications at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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

The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. Shade is provided by trees and building overhangs in the playground. LPA did not observe any bodies of water. Lisa states that the Facility does not provide transportation.

Lisa Bennett, 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.

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/process.

Exit interview conducted and report was reviewed with the Director, Lisa Bennett. No deficiencies cited during today's inspection. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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