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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376105204
Report Date: 05/23/2025
Date Signed: 05/23/2025 01:59:07 PM

Document Has Been Signed on 05/23/2025 01:59 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 DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KCE CHAMPIONS LLC @ ST. DUNSTAN'SFACILITY NUMBER:
376105204
ADMINISTRATOR/
DIRECTOR:		KATHRYN CZERWINSKIFACILITY TYPE:
860
ADDRESS:6556 PARK RIDGE BLVDTELEPHONE:
(619) 200-5747
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY: 50TOTAL ENROLLED CHILDREN: 43CENSUS: 0DATE:
05/23/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Katie Czerwinski/Area ManagerTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On 5/23/2025 at 8:40am, Licensing Program Analyst (LPA), Selina Siao conducted an announced Pre-Licensing inspection for a new license. Upon arrival, LPA met with Champions Area Managers Katie Czerwinski and Marie Ayala and Director Audrey Larson. Applicant is requesting to be licensed for 50 school-age children (ages 5 to 12 years old) in the Parish Hall and Youth Building. Hours of operation will be Monday to Friday from 6/2/2025 to 8/1/2025 during the hours of 7:30am to 5:30pm and the program will close the week of 06/30/2025 to 7/04/2025.

All indoor and outdoor activity space utilized for the children was inspected today. LPA informed facility representatives that staff are required to maintain direct visual supervision of the children at all times during indoor and outdoor activities. When medications are on site, Katie Czerwinski stated that they will be in office storage and a mini refrigerator will be purchase if there are any children that has medication that needs to be stored in the refrigerator and other medication will be store in the purple back packs in a locked bag located in the office. A fully equipped first aid kit is in office located in the Parish Hall. There is an operational carbon monoxide detector on site located in both the Parish Hall and Youth Building room. All required licensing documents were observed posted in the main day care Parish Hall room. Children will be signed in and out via the Lilio app.

LPA continued to tour the facility and measured all indoor and outdoor activity space. Total indoor activity space measured to be 3826.34 square feet, which is sufficient to accommodate the requested capacity of 50 Children. LPA observed all indoor activity space to be complete with safe age-appropriate furniture and equipment, including tables, chairs, cubbies/baskets, bookshelves, and other activity supplies for the children. Drinking water is available in the classrooms via the large igloo located in the Parish Hall and a
NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Selina Siao
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KCE CHAMPIONS LLC @ ST. DUNSTAN'S
FACILITY NUMBER: 376105204
VISIT DATE: 05/23/2025
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portable pitcher will be in the youth building. LPA observed most hazardous items to be inaccessible to children. Katie Czerwinski stated that there are no bodies of water or weapons on the property. Fire clearance was granted on 05/08/2025.

LPA observed a total of 8 sinks, 8 toilets and 2 urinals available for children’s use. These are sufficient to accommodate the requested capacity of 50 children. Restrooms afford privacy for children. There is a separate staff restroom equipped with a toilet, urinal and two sinks. The isolation area for children who are ill will be the Director’s office in the Parish Hall and the staff’s restroom located in the Youth Building.



Facility will provide AM and PM snacks to children. The kitchen area currently includes a refrigerator, microwave, small electric stove and a stackable washer and dryer. The kitchen areas observed to be free of The facility currently has a fully fenced playground area which is separate from other components. Fencing is via a chain link that is at least four feet high the current enclosed outdoor playground measured to be 1733.27 square feet which is only sufficient to accommodate up to 23 children at one time. Facility is planning to designate a large grassy area that is located in the front of Parish Hall and that area measured to be 49 feet by 71 feet and 4 inches as an additional outdoor area and that area measured to be 3499.58 square feet. The total square footage for both outdoor activity spaces is 5232.85 square feet, which is sufficient to accommodate the requested capacity of 50 children. Shade is provided via trees, umbrella and pop-up canopy. The climbing structure on the playground are for children ages 2- 5 years old but facility will have outdoor play equipment for children to use. There is adequate cushioning in fall zones of climber provided by wood chips. Drinking water is available via the portable pitchers and it gets refill with the kitchen sink water and filtered drinking fountain in the youth room and outside. Children will have their own water bottles while on site and facility will also have extra water bottles available to the children. LPA observed all hazardous items on the playground to be inaccessible to children. Area manager Katie Czerwinski was reminded that any changes to the facility must be reported to and approved by Community Care Licensing. rodents and/or vermin.

Facility representatives were reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Selina Siao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KCE CHAMPIONS LLC @ ST. DUNSTAN'S
FACILITY NUMBER: 376105204
VISIT DATE: 05/23/2025
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This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A 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) or (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 reviewed with facility representatives the LIC 311A, Records to Be Maintained at The Facility, for child’s records, personnel records, administrative records, and documents to be posted.The following corrections are needed prior to the issuance of the license:

· Latch up all the drawers and cabinets in the kitchen that is located in the Youth Building.


· Lock the storage door located in the kitchen and obtain the key located in the youth room kitchen.
· Remove all the items with labels “keep out of reach of children” in the staff’s /boy’s sink counter located in the Youth Building.
· Remove all the items with labels “keep out of reach of children” in the women’s restroom located in the Parish Hall.
· Install a four feet high fence to enclose the grassy area that will be used as an outdoor area for the children.
· Put signs to designate men’s restroom that will be for adults located in the Youth Building.

Facility representative Katie Czerwinski understands that all proof of corrections must be provided to the Department within 30 days, or the application may be denied.

Exit interview conducted and report was reviewed with the Area Manager Katie Czerwinski.

Facility representative was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.


NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Selina Siao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KCE CHAMPIONS LLC @ ST. DUNSTAN'S
FACILITY NUMBER: 376105204
VISIT DATE: 05/23/2025
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP).


NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Selina Siao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC809 (FAS) - (06/04)
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