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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004699
Report Date: 09/28/2022
Date Signed: 09/28/2022 04:34:27 PM

Document Has Been Signed on 09/28/2022 04:34 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: 109CENSUS: 38DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jacqueline NavarroTIME COMPLETED:
04:45 PM
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On September 28, 2022, Licensing Program Analyst (LPA) Van conducted an unannounced inspection in conjunction with the Preschool program's required annual inspection and met with the new Director, Jacqueline Navarro. The purpose of the inspection was explained, and granted entry to the facility. Present today are 38 school-age children supervised by 4 staff members. The facility complies with the staff-children ratios today. All staff members have criminal record clearances on file. 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 – 8:30 am, and the PM hours are 2:00 pm – 6 pm. The Center uses classrooms #1, #2, #12 - #15, portable #17, the library, and the multipurpose room. Classrooms #1, #2, #12-#15, the library, and the multipurpose room were not used today.

The facility was inspected indoors and outdoors for Health and Safety hazards. The Center is clean, organized, in good repair, and has proper temperature and ventilation. Classrooms have age-appropriate toys and learning materials. Furniture appears steady and free from defects. The First Aid Kit is fully stocked. Emergency supplies are properly maintained and kept inaccessible to children. LPA observed all cleaning products and disinfectants are stored in the cabinets with child-proof locked. The facility has several restrooms (Girls and Boys). Restrooms are maintained clean, in good repair, and with adequate supplies. Staff uses a separate restroom located outside the office. The facility's food preparation area is clean.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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: 09/28/2022
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Per Director, the fire and earthquake drills are conducted at least once every six months, and the last drills were conducted on 9/27/2022. However, the Director did not document the drill. LPA inspected the outdoor play area for safety hazards and dangerous conditions. The play yard is completely fenced. LPA observed play area is equipped with a climbing structure and tether ball court. Drinking water is readily available indoors and outdoors for daycare children. The program provides afternoon snacks. Per Director, the facility has a child with medication. However, the child's medication was not stored at the Center but carried along in the child's backpack. Director understood that medications need to be in the original box, unaltered, and have the child's name. 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).

In today's inspection, LPA reviewed ten random children's and staff records samples. According to the Director, the teacher assigned to the Kindergarten will come to the children's classroom and pick them up. Older children will line up on the ramp, the teacher will sign in all children, and a head count will be conducted before entering the classroom. All children had a medical assessment, and required licensing forms were completed. Teachers have records of valid Pediatric FirstAid/CPR cards in the file and the required immunization. All staff has criminal record clearance.

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: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 09/28/2022
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The 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

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.

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 visit the CCLD website at www.ccld.ca.gov for licensing regulations and new updates. The Director can also email at childcareadvocatesprogram@dss.ca.gov and ask for the updates to be added to the email list.



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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 09/28/2022
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

During the inspection, LPA requested an update Designation of Responsibility (LIC 308); Basic Pest Management Certification for all staff;

No deficiencies were cited today. An exit interview was conducted, and the report was reviewed with the Director, Jacqueline Navarro. Today's report, September 28, 2022, and site notice were provided to the Director. LPA informed the Director that the site visit notice must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC809 (FAS) - (06/04)
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