414000082-10-14-2020-05-CC-GASL-BUDQ67-20201014115303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414000082
Report Date: 09/09/2020
Date Signed: 10/14/2020 11:53:09 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	CHAMPIONS-LAS LOMITAS ELEMENTARY (SA)		FACILITY NUMBER:	414000082
ADMINISTRATOR:	PFEIFFER, SHARON		FACILITY TYPE:	840
ADDRESS:	299 ALAMEDA DE LAS PULGAS		TELEPHONE:	(650) 250-3658
CITY:	ATHERTON	STATE: CA	ZIP CODE:	94027
CAPACITY:	90	CENSUS: 20	DATE:	09/09/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Brennan Bennardo		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Glenn Schnell met with Area Manager/Licensee Representative Brennan Bennardo today for a case management inspection in response to a request to increase the capacity of the school age program from 90 to 120 children ages 5-12. The facility is locate and at Las Lomitas Elementary School campus. This program will operate Monday - Friday; 6:30 AM to 6:00 PM during the COVID-19 pandemic, and until children can return to in person classroom instruction, the program will be providing care and supervision to children while engaged in distance learning. There is currently a waiver approval process in place to allow for this. The Licensee has the approval of the School District to operate on the Elementary School campus during the COVID-19 pandemic and is in the process of obtaining a letter from the District to do so and the letter must indicate a description of coordination efforts with San Mateo County Dept. of Public Health. The Licensee is in process of completing an attestation letter which addresses the conditions of operation for waiver approval. The facility was inspected today, indoor and outdoor, for health and safety hazards and measured to calculate capacity. Since the school age program is operated on a functioning elementary school site, the rooms can be used as elementary school classrooms, and the rooms will be leased by KCE Champions, the program is exempt from outdoor square footage requirements, fencing requirements, toilet/sink ratios, isolation requirements and indoor square footage requirements. The school age children will have use of the elementary school playgrounds and outside bathrooms which provide individual privacy. Staff will escort children to and from the bathrooms located on the campus of the elementary school and will ensure the bathrooms are clean and safe prior to being used by any children. Continued on next page.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Glenn A Schnell	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHAMPIONS-LAS LOMITAS ELEMENTARY (SA)	FACILITY NUMBER: 414000082
	VISIT DATE: 09/09/2020

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

Indoor: Rooms to be used will be: 3,37,39, 9 and 10 and room 1A. Rooms 3 and 37 will be used as additional indoor space and will not be used when in use by the preschool program. Rooms 9 and 10 will not be used when in use by the preschool program. The Licensee still needs to obtain a capacity letter from the school principal that confirms the maximum capacity of children (not square footage) for each room to be used.
The indoor space for children is observed today to be clean and all furnishing, toys and equipment observed to be safe and in good condition. There is storage space for children's personal belongings. The indoor spaces are equipped with a fire extinguisher, smoke and carbon monoxide detectors, garbage cans with tight-fitting lids, first aid and emergency supplies. Rooms 3 and 37 have food prep areas with refrigerators.
Sign-in/Sign out of the children will occur outside of the facility classrooms during the COVID-19 pandemic. Bathrooms were observed to be clean and with no health and safety hazards. Bathrooms are located on the school campus outside of the proposed rooms to be used. The sinks accessible to children do not deliver water warmer than 120 degrees. The program will provide a pitcher with water and cups for water access indoors and outdoors. All toxins and other hazardous items will be stored in a locked cabinet in the classroom and will be inaccessible to children. Isolation of ill children will be located in the school office.
Outdoor: The outdoor area is the elementary school playground. The playground was observed to be clean, safe and equipped with toys and equipment for children. Since the outdoor space is used for elementary school children as well as children that will be in this licensed after school care program, the applicant will ensure close supervision of the children and ensure there is not commingling of children from the elementary school and community in general, and the children participating in this after school care program. Pitchers of water and cups will be used for drinking water outside. Shade for children is provided by shade structures.Continued on next page.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Glenn A Schnell	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHAMPIONS-LAS LOMITAS ELEMENTARY (SA)	FACILITY NUMBER: 414000082
	VISIT DATE: 09/09/2020

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 items were reviewed as part of today's visit: Record keeping for staff, children and facility records, Care and Supervision of the Children, Child Discipline Procedures, Emergency Evacuation Procedures, Medication Policies, Isolation of Sick Children, Food Service, Transportation-none provided, Parents Rights, and Reporting Requirements. LPA Schnell observed all required postings.
The facility will conduct monthly disaster drills and a log will be maintained for review upon request. The fire inspection was conducted, and approval was received on 8/27/20, however room 1A is not listed as a room to be used.
This facility will provide Incidental Medical Services – IMS.

At this time, applications for licensure and active licenses for licensed facilities on school campuses is currently under review. A license for an increase in capacity will be recommended once the following is received:
-An updated request letter from the licensee for the capacity increase, indicating the specific rooms to be used/added.
-An updated fire clearance from the Menlo Fire Department adding room 1A
-A room capacity letter from the Elementary School principal indicating the rooms to be used by KCE and the capacity for each one.
-Updated LIC 401 due to the increase in capacity
-Updated LIC 500 due to the increase in capacity
-Update LIC 610 due to increase in capacity and possibility of additional staff added to emergency protocols
-Updated School campus map that clearly indicates the classrooms, bathrooms, and outdoor areas KCE will be using.
-LIC 999's for the rooms that KCE will be using. Please ensure the LIC 999's contain all of the elements requested on the LIC 610 and the LIC 999
-Storage in room 1A needs to be removed
-Department approved waiver to operate and conduct full day care and supervision to children engaged in distance learning. (Licensee completing attestation letter and obtaining approval letter from the school principal/District)

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Glenn A Schnell	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3