414004699-10-1-2020-05-CC-CINO-BTYU29-20201001151135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004699
Report Date: 08/20/2020
Date Signed: 10/01/2020 03:11:42 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		FACILITY NUMBER:	414004699
ADMINISTRATOR:	BENNARDO, BRENNAN		FACILITY TYPE:	840
ADDRESS:	801 HOWARD AVENUE		TELEPHONE:	(408) 771-6801
CITY:	BURLINGAME,	STATE: CA	ZIP CODE:	94010
CAPACITY:	91	CENSUS: 0	DATE:	08/20/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Area Manager, Brennan Bennardo and Site Supervisor, Melisa Patel		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), Cindy Interiano conducted a PreLicensing inspection and met with Area Manager, Brennan Bennardo and Site Supervisor, Melisa Patel via a Tele-Inspection. Purpose of the inspection was explained to Area Manager and Site Supervisor. Facility has requested a license for 91 school age children (ages 5-12) to operate on the Washington Elementary School site. Program will operate M-F, 630a-630p. Once school is able to return to normal/hybrid hours, program will operate M-F, 6:30a-8:30a and 2p-6p. Program will operate in: Building 1, Rooms #19, MPR, and Library; Building 2, Rooms #1 and #2; and Building 3, Rooms #12 and #13. Program is scheduled to start on 08/26/2020. Area Manager and Site Supervisor lead LPA on a virtual inspection of the facility indoors and outdoors for Health and Safety hazards. Classrooms have age appropriate toys and equipment for children. Rooms are equipped with an industrial fire alarm, a smoke and carbon monoxide detector, and a fire extinguisher. Program has exclusive/scheduled use of accessible boys’ and girls’ restrooms on campus: in Building 1, a boys’ restroom with 3 toilets, 3 urinals, and 3 sinks and girls’ restroom with 5 toilets and 5 sinks; in Building 2, a boys’ and girls’ restroom, each with 1 toilet and 1 sink; and in Building 3, a boys’ and girls’ restroom, each with 1 toilet and 1 sink. Restrooms are maintained clean, in good repair, and with adequate supplies. Program will have exclusive/scheduled use of sections of the Elementary School Playground. Children are not allowed to go beyond the set boundaries of the playground, unless supervised by a staff. Outdoor play area is free of debris and dangerous conditions. All outdoor toys and equipment are age appropriate and in good repair. Classrooms appear to have proper ventilation and sufficient lighting. First Aid Kit and Emergency supplies are properly maintained and kept inaccessible to children. Cleaning products and toxins are maintained inaccessible to children. Drinking water is readily available indoors and outdoors. Program will provide snacks and children will bring their own meals. All required postings are posted near the designated sign in/out area. See Page 2. . .

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KCE CHAMPIONS LLC @WASHINGTON ELEMENTARY	FACILITY NUMBER: 414004699
	VISIT DATE: 08/20/2020

NARRATIVE

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Page 2. . .

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

Facility was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

Area Manager and Site Supervisor were informed about the Provider Information Notices (PINs) on CCLD website.

Area Manager and Site Supervisor were advised of Mandated Reporter Training available on CCLD website.

During the tele-inspection, LPA provided Technical Assistance for Covid-19 guidelines, including Social Distancing, proper use of PPE equipment, and cleaning / disinfecting / sanitizing of commonly used areas/items.

Fire Clearance dated 07/28/20 has been granted for 91 School age children.

Area Manager and Site Supervisor were advised that a follow-up inspection will be conducted in the future.

Prior to licensure for 91School Age children,
>Final review is required from the Department.

>This report will be emailed to facility. This report must be available in the facility for public review. Any additional questions to call Office, M-F, 8a-5p, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020

LIC809 (FAS) - (06/04)

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