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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004581
Report Date: 08/26/2021
Date Signed: 08/26/2021 11:28:42 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:KCE CHAMPIONS LLC @ ROLLINGWOODFACILITY NUMBER:
414004581
ADMINISTRATOR:SAUCEDA, CYNTHIAFACILITY TYPE:
840
ADDRESS:2500 COTTONWOOD DRIVETELEPHONE:
(408) 771-6801
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:61CENSUS: 0DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cynthia SaucedaTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Saini met with Director Cynthia Sauceda for an unannounced Annual Random Inspection.The purpose of the inspection was explained. At 9:30am, LPA did not observe any children in care. Per director, there were 4 children present in the before school program. LPA observed that all children were sign in and sign out properly. Program operates M-F, before- school 7:00-9:30am and after-school from 12:00-6:00PM, in Room #15 and the multi-purpose room on the Rollingwood Elementary School site.

The facility was inspected indoor and outdoor today for health and safety hazards and the following was observed; There are no bodies of water, firearms, or weapons on the premises. The center is in good condition with proper temperature and ventilation and is free of any hazards. All furniture is in good repair. The Center has age-appropriate toys and equipment. The outdoor play area is fenced for supervision. The play structure is age-appropriate and in good condition. There are separate bathrooms for boys and girls.There is drinking water readily available for children. The program provides daily snacks and lunch. The classroom has appropriate postings. The facility has first aid kit available. The facility has fully charged fire extinguisher, and a working telephone available. LPA reviewed 3 children records. All children have a record of emergency identification information on file. The site Director has a current Pediatric First Aid/CPR certificate on the file.

During inspection,

• Site Director was provided information regarding Incidental Medical Services (IMS). For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Section 101226. When any IMS is provided, a plan for providing IMS must be submitted to the Department.

• Site Director was reminded as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.662.

• Site Director was reminded about Mandated Reporter Training available on the CCLD website. Training must be completed every two years. (Websites: www.ccld.ca.gov or www.mandatedreporterca.com)

• Site Director was reminded about the Provider Information Notices (PINs) on the CCLD website.

No deficiencies were cited today.This report was reviewed and discussed with Site Supervisor Cynthia Sauceda and will be sent to the site supervisor at the email address ch001597@discoverchampions.com by the close of business on 08/26/2021. Any additional questions, call CCLD Office, Monday - Friday, 8am - 5pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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