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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701264
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:17:25 PM

Document Has Been Signed on 04/11/2023 03:17 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KCE CHAMPIONS LLC AT SEQUOIA ELEMENTARY PRESCHOOLFACILITY NUMBER:
376701264
ADMINISTRATOR:REBECCA ADAMSFACILITY TYPE:
850
ADDRESS:4690 LIMERICK AVENUETELEPHONE:
(619) 972-1425
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 24TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Alma MejiaTIME COMPLETED:
03:30 PM
NARRATIVE
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On April 11, 2023 at 12:40 p.m.. Licensing Program Analyst (LPA) Leilani Curtis visited the facility to conduct an annual inspection. Upon arrival LPA met with Acting Director/Area Director Alma Mejia and proceeded to tour the facility. LPA provided the LIC 125, Entrance Checklist to Director Mejia. Also present were 6 children with one staff member. A second staff member arrived at 2:30 p.m. Appropriate ratios and capacity were observed. Staff members have the required background clearances and are associated to the facility. No excluded individuals are present. Furniture and age appropriate equipment is in good condition indoors and outdoors. Children's toilets and hand washing facilities are sanitary. Rooms are safe and clean. Food preparation area is clean, food and beverages are stored in covered containers at 45 degrees F or less if required, and storage containers for solid waste are covered. Drinking water is readily accessible inside and outside the classroom. All disinfectants, cleaning solutions, and other hazardous items are inaccessible to children through latches and locks. Storage area for poisons is locked. Medications are kept in a safe place inaccessible to children. The outdoor play area is fenced. Playground equipment is in safe condition, free of sharp, loose or pointed parts. The areas around or under high climbing equipment, swings, slides, and similar equipment is cushioned with material that absorbs a fall. The outdoor play area has trees used for shade. There are no bodies of water or weapons at this facility. There is an operational carbon monoxide detector at the facility. First Aid/CPR certifications were reviewed and are in compliance. The last documented disaster/fire drill occurred on 2/24/22.

This facility provides Incidental Medical Services – IMS. The director states that there are no children currently enrolled who require Incidental Medical Services. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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.

SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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Document Has Been Signed on 04/11/2023 03:17 PM - It Cannot Be Edited


Created By: Grace Curtis On 04/11/2023 at 02:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KCE CHAMPIONS LLC AT SEQUOIA ELEMENTARY PRESCHOOL
FACILITY NUMBER: 376701264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The last documented disaster/fire drill occurred on 2/24/22. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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The director states that she will conduct and document a disaster/fire drill and send LPA a copy of the documentation via email by 4/21/23.
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one out of six children present was not signed in by parent/guardian using their full legal signature. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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The director states that she will send a letter detailing the sign in/sign out requirements, and sign in/sign out acknowledgment form to all parents/guardians of children enrolled. The director will send LPA a copy of the letter and acknowledgment forms via email by 4/21/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tashima Daniel
LICENSING EVALUATOR NAME:Grace Curtis
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: KCE CHAMPIONS LLC AT SEQUOIA ELEMENTARY PRESCHOOL
FACILITY NUMBER: 376701264
VISIT DATE: 04/11/2023
NARRATIVE
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Admission agreement, emergency information and medical assessment forms were reviewed for some children. The sign in/sign out sheet was reviewed. The parent/guardian of one child present did not sign the child in using their full legal signature. Staff records contain documentation of education, training, and/or experience. Menus are posted. LPA obtained an updated Emergency Disaster Plan for Child Care Centers- LIC610, Personnel Report-LIC500 and Children’s Roster-LIC9040.

See LIC809D for cited deficiencies.

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.

Director Mejia 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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director Mejia.

SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Grace Curtis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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