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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004699
Report Date: 09/17/2021
Date Signed: 09/17/2021 04:47:11 PM

Document Has Been Signed on 09/17/2021 04:47 PM - It Cannot Be Edited

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 (SA)FACILITY NUMBER:
414004699
ADMINISTRATOR:NGUYEN, KRISTYFACILITY TYPE:
840
ADDRESS:801 HOWARD AVENUETELEPHONE:
(650) 906-2506
CITY:BURLINGAME,STATE: CAZIP CODE:
94010
CAPACITY: 109TOTAL ENROLLED CHILDREN: 0CENSUS: 24DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kristy NguyenTIME COMPLETED:
04:50 PM
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On September 17, 2021, Licensing Program Analyst (LPA) Van met with the Site Director, Kristy Nguyen, for an unannounced annual inspection. The purpose of the inspection was explained. This facility is a school-aged after-school program and operates in the Washington Elementary school in Burlingame. The days and hours of operations are Monday – Friday, the AM hours are 7:00 am – 8:45 am, and the PM hours are 2:00 pm – 6 pm. Present today were two staff supervising 24 children and utilizing room # 17.

LPA, along with the Site Director, inspected the facility for health and safety hazards. A variety of age-appropriate toys and learning materials for children are available in the classroom. There are no pools, spas, or other bodies of water at the facility. Per Director, there are no firearms or weapons on the premises. The facility has a smoke detector, a carbon monoxide detector, fully charged fire extinguishers, and a working telephone. All cleaning solutions, poisons, and other dangerous chemicals stored are inaccessible to children. Sick children will be separated from the group and waited for parents to pick them up in the staff office. The facility is in good repair and free of any hazards with proper temperature and ventilation. The school-age children will be used the school's boys/girl bathrooms. All the bathrooms, toilets, and sinks are clean and well sanitized. All solid waste bins have a proper tight-fitted lid on top, and the facility has a water refill station readily available for children. The outdoor playground area is in good repair, and play structures are free of any loose parts. continued>>>>
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
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)
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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 (SA)
FACILITY NUMBER: 414004699
VISIT DATE: 09/17/2021
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In today's inspection, LPA reviewed random samples of staff and children's records. According to the Director, the teacher assigned to the children's group will pick up the children in their classroom and sign them in. All children have required licensing forms, and all staff has criminal record clearance. The staff has a record of valid Pediatric FirstAid/CPR card in the file and the required immunization. LPA also observed that the facility had posted the required forms. (i.e., License, waivers, Notification of Parent's Rights, and Notification of Personal Rights). The Director stated that Fire and Earthquake drills are done each month.

LPA reminded the Director that as of September 1, 2016. A person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles. LPA observed that the facility has a record of required immunization of all staff.

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.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
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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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 (SA)
FACILITY NUMBER: 414004699
VISIT DATE: 09/17/2021
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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 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

LPA encouraged the Director to frequently visit the CCLD website at www.ccld.ca.gov for licensing regulations and new updates. Director 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.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
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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