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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004699
Report Date: 05/02/2024
Date Signed: 05/02/2024 04:31:27 PM

Document Has Been Signed on 05/02/2024 04:31 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:KCE CHAMPIONS LLC @ WASHINGTON ELEMENTARY (SA)FACILITY NUMBER:
414004699
ADMINISTRATOR/
DIRECTOR:		NAVARRO, JACQUELINEFACILITY TYPE:
840
ADDRESS:801 HOWARD AVENUETELEPHONE:
(650) 906-2506
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 109TOTAL ENROLLED CHILDREN: 77CENSUS: 49DATE:
05/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:35 PM
MET WITH:Director, Nathasia AradanasTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On May 2, 2024 at approximately 2:35pm, Licensing Program Analysts (LPAs) Melissa Zaragoza and Catrina Quimbo conducted an unannounced, case management visit to Champions after-school program in regards to an incident that was self reported April 22, 2024. LPAs met with site director, Nathasia Aradanas, and explained the purpose of the visit.

Facility is an after-school program operating at Washington Elementary. After-school program is currently operating in library, MPR, and classroom next to champions preschool program. Present during LPA's visit included 9 instructor staff, 49 school age children, and 4 preschool age children.

On April 17, 2024 Staff 1(S1) and Child 1 (C1) were located on the playground's turf at facility. C1 was kicking S1. Per site director, S1 put their hands up to stop C1 from kicking. C1 hit their mouth on S1's hands, resulting in a lip bleed. C1 was provided first aid at facility by Champions staff.

C1's family was not notified about incident at Champions program. Site director was informed of incident by C1's family on 4/18. No medical treatment for C1 was required. Champions program conducted an internal investigation in regards to incident. Internal investigation included staff interviews, self reporting incident to elementary school's principal, superintendent, and CPS. A cross report of incident was also made with Burlingame police department. S1 was not present at program during internal investigation.

C1 returned to program 4/19 while internal investigation was being conducted. Burlingame police department conducted separate investigation, concluding incident to be an accident on 4/25. S1 returned to Champions program 4/26.

Since incident, mandatory staff meeting was conducted, reinforcing safety training, importance of communication and over sharing with children's families and injury protocols of incident reports.

Per site director, C1 has been attending after school program as per C1's normal. During today's visit, site director provided LPAs with supportive documents in regards to incident.

No deficiencies were issued during today's visit. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with facility representative, Nathasia Aradanas.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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