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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004698
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:49:23 PM

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 @ WASHINGTON ELEMENTARY (PS)FACILITY NUMBER:
414004698
ADMINISTRATOR:NGUYEN, KRISTYFACILITY TYPE:
850
ADDRESS:801 HOWARD AVENUETELEPHONE:
(650) 906-2506
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:12CENSUS: 4DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kristy NguyenTIME COMPLETED:
01:45 PM
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On September 17, 2021, Licensing Program Analyst (LPA) Van made an unannounced Annual Random inspection and met with new Site Director Kristy Nguyen. The facility is operating in the Washington Elementary School site. The purpose of the inspection was explained and granted entry to the facility by the Director. Presently, Two staff were supervising four children at the Center. The Hours of operation are Monday to Friday, 8:30 am to 5:00 pm.

LPA and Director inspected the facility for health and safety hazards. LPA observed no bodies of water on the premises. Per Director, there are no firearms or weapons in the Center. The facility has a carbon monoxide detector, a centralized smoke alarm, a fully charged fire extinguisher, and a working telephone. The classroom is in good condition with proper temperature and ventilation and is free of any hazards. All classrooms have age-appropriate toys, furniture, and equipment. Furniture appears steady and in good repair. All toilets, hand washing facilities are in good working condition with proper sanitation in place. All cleaning solutions, poisons, and other dangerous chemicals are stored in an off-limit area inaccessible to children in care. The facility currently has an outdoor waiver, which allows an outdoor play area barricaded with cones. The outdoor play structures are age-appropriate and in good condition, with sufficient cushioning underneath.

LPA observed that the facility had posted the required forms. (i.e., License, menus, waivers, Notification of Parent's Rights, Notification of Personal Rights, Car Seat Law, and Emergency Disaster Plan). Per Director, the Center provides morning and afternoon snacks, and the children's lunch is brought from home. Drinking water is available for children indoors and outdoors, and the facility has a refillable water station readily available for children. All storage containers for solid waste within the Center have a proper tight-fitting cover. continued>>>
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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: KCE CHAMPIONS LLC @ WASHINGTON ELEMENTARY (PS)
FACILITY NUMBER: 414004698
VISIT DATE: 09/17/2021
NARRATIVE
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During the inspection, random children's records and personnel records were reviewed. LPA observed that the facility has a sign-in/out sheet outside of the classroom, with parents' or authorized representatives' complete signatures. LPA observed facility records each child's authorized representative's names, addresses, and telephone numbers. Staff records review showed multiple staff members have a record of valid CPR in file and immunization on their respective file. LPA reviewed the educational qualification of all the teachers. Director stated that the fire and earthquake drill is conducted every month, and the last drill was conducted on August 9, 2021.

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 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.

The Director was informed about Mandated Reporter training available on the CCLD website. In addition to AB1207 training required to complete every two years by the Licensee and all staff hired, a one-time General Training is also required. Training can be taken online at www.mandaterreporterca.com. Also, the Director was reminded of Pesticides training. Information on the DPR website at: www.cdpr.ca.gov/shoolipm/childcare continued>>>
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 2 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: KCE CHAMPIONS LLC @ WASHINGTON ELEMENTARY (PS)
FACILITY NUMBER: 414004698
VISIT DATE: 09/17/2021
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LPA encouraged the Director to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

No deficiencies are cited today. An exit interview was conducted, and the report was reviewed with the Director, Kristy Nguyen. Today's report, 9/17/2021, and notice of site visit will be sent to the Director by email at Kristy.Nguyen@discoverchampions.com by the close of business on 9/17/21. Confirmation of receipt is required. LPA informed the Director that the notice of site visit must be posted for 30 days.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
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