Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841007
Report Date: 08/13/2015 12:00:00 AM
Date Signed 08/13/2015 01:58:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CHAMPIONS AT WOODCREST ELEMENTARYFACILITY NUMBER:
334841007
ADMINISTRATOR:GALBAN, MELISSAFACILITY TYPE:
840
ADDRESS:16940 KRAMERIA AVENUETELEPHONE:
(951) 780-1215
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:35CENSUS: 0DATE:
08/13/2015
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Amanda CarlsonTIME COMPLETED:
02:10 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
The purpose of this Case Management visit was initiated by the licensee. The licensed program had to relocate from 101 to the portable, room 19 as the school needed room 101 for growth. Licensing Program Analyst (LPA), Judith Simms, toured the portable. There is one bathroom inside, two sinks and a drinking fountain. The last fire inspection for the school was, 12/1/14. The days and hours of operation will be: Monday through Friday 6:00am - 8:45am and 12:20pm - 6:00pm in room #19. Phone number: (951) 780-1215. Waivers are not needed as the program operates before and after-school, in-service days and during school holidays only.
Per Health and Safety code Section 1596.806. This program is exempt from square footage requirements and toilet and sink requirements, fencing outdoor activity requirements, and isolation area requirement as the program is operated on a functioning school site which has been approved for public accommodation and instruction. Also exempt from a fire clearance if a certification statement signed by the superintendent of the schools or the office of the state Architect is provided, stating that the classroom building is of sufficient size to accommodate public instruction and the requested capacity.
There is no Limiting factor for capacity. Capacity is limited to 35 children.
The following was observed:
Classroom is adequately equipped with age and size appropriate furniture and equipment
Water fountain supply drinking water in the indoor activity space
Playground is enclosed by an appropriate fence
Outdoor activity area is supplied with age and size appropriate equipment
SUPERVISOR'S NAME: Lya JohnsonTELEPHONE: (951) 782-4216
LICENSING EVALUATOR NAME: Judith SimmsTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2015
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHAMPIONS AT WOODCREST ELEMENTARY
FACILITY NUMBER: 334841007
VISIT DATE: 08/13/2015
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
The following civil penalty information was discussed: If a facility is cited for a serious deficiency and then repeats the same violation within a 12 month period, an immediate penalty of $150 shall be assessed and a penalty of $50 per day shall be assessed until the deficiency is corrected. If the facility repeats the same violation for a third time within the same 12 month period, the facility will be cited and assessed an immediate penalty of $150 for that day and $150 per day until the deficiency is corrected. The applicant was advised how to access forms and regulations for Child Care Centers online at www.dss.cahwnet.gov or ccld.ca.gov
The applicant was notified that violations of the sections pertaining to Parent’s Rights sections 101218.1(b)(8), (c), (d), (e), (e)(1), or (e)(2) are subject to three tier civil penalties.
The applicant was advised that, once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.
· - AB 2084 - Nutritious Beverages in Child Care Facilities effective January 1, 2012 - was explained that only low-fat or non-fat milk is to be served to children 2 years of age or older; and limit juice to one serving of 100% juice per day; serve no beverages with added sweeteners; and water must be available and accessible to children throughout the day.
· AB 978 – Zero Tolerance Related Regulations went into effect January 18, 2011 – In accordance with California Health and Safety Code Section 1596.99(c)/1597.58(c) – it was explained that an immediate $150 Civil penalty will be assessed for each serious violation and a civil penalty of $150 per day per violation will be assessed until corrected.
SUPERVISOR'S NAME: Lya JohnsonTELEPHONE: (951) 782-4216
LICENSING EVALUATOR NAME: Judith SimmsTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2015
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHAMPIONS AT WOODCREST ELEMENTARY
FACILITY NUMBER: 334841007
VISIT DATE: 08/13/2015
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
An adequate amount of cushioning material (cork flooring and sand) is in place under play equipment
Adequate shade is provided by large trees
Drinking water is provided in the outdoor play area by igloo and cups and outside water fountains
Food preparation area is equipped with small refrigerator, 2 sinks in the classroom, storage area, utensils, and adequate amount of food supplies
The office area is located at the front of the classroom by the entry door and will serve as the isolation area for ill children temporarily until parents arrive
Staff bathroom will also be used as the isolation bathroom and is located outside of the classroom by the play ground
Medication will be stored in locked cabinet and refrigerated medication will be in key locked box in the refrigerator, and is inaccessible to children
Medication administration forms were reviewed
First Aid kit is complete
Sign in/Sign out record was reviewed and meets regulation requirements
Component I and III Orientation was completed
A review of staff records on 8/13/15, indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
The applicant has been informed that all employees must be associated to the facility. If the licensee fails to have proof of a fingerprint clearance or fails to associate a previously cleared individual to the facility, a civil penalty of $100.00, per day the person has been present, will be assessed. The first violation is subject to the penalty for up to five days. If there is a subsequent violation in a 12 month period, the fine will continue for up to 30 days.
SUPERVISOR'S NAME: Lya JohnsonTELEPHONE: (951) 782-4216
LICENSING EVALUATOR NAME: Judith SimmsTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2015
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CHAMPIONS AT WOODCREST ELEMENTARY
FACILITY NUMBER: 334841007
VISIT DATE: 08/13/2015
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
· AB 2621 Effective 1596.819(a) Except as otherwise prohibited by law, the department shall post licensing information on its Internet Web site as follows: (1) For each child day care facility as defined in Section 1596.750, except family day care homes, the information shall include, but is not limited to, the name and address of the facility, the licensed capacity of the facility, the status of the license, and the number of site visits, including the number of citations, substantiated and inconclusive complaint inspections, and non-complaint inspections during the preceding five year period. (b) The department shall update the information posted under subdivision (a) on at least a monthly basis.
· AB 2386 – Effective January 1, 2015 Health and Safety Code 1596.954 states: Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of
· Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

Prior to licensure the following is needed:
1. Carbon monoxide detector (send picture for proof of correction)
2. Director needs 7 hour health and safety course scan copy
3. Need chain/lock for hot water tank under cabinet in classroom


The licensee stated "The facility provides Incidental Medical Services - IMS. LPA reviewed storage of medication, equipment/supplies. At this time, there were no children's/staffs records for review". The licensee was informed that she has 30 days to submit the IMS-PO to LPA. The room change application will be submitted for approval with a maximum capacity of 35, once all corrections have been received. An exit interview was conducted and a copy of this report was provided to the licensee, Amanda Carlson on this date. A copy of this report must be made available to the public for 3 years.
SUPERVISOR'S NAME: Lya JohnsonTELEPHONE: (951) 782-4216
LICENSING EVALUATOR NAME: Judith SimmsTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2015
LIC809 (FAS) - (06/04)
Page: 4 of 4