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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001605
Report Date: 06/08/2022
Date Signed: 06/08/2022 04:48:40 PM

Document Has Been Signed on 06/08/2022 04:48 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 @ ROOSEVELT ELEMENTARYFACILITY NUMBER:
414001605
ADMINISTRATOR:ZAHAR, CHIRINEFACILITY TYPE:
840
ADDRESS:1151 VANCOUVER AVENUETELEPHONE:
(650) 863-1529
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 112TOTAL ENROLLED CHILDREN: 112CENSUS: 44DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Chirine ZaharTIME COMPLETED:
05:00 PM
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On June 8, 2022, Licensing Program Analyst (LPA) Van met with the Site Director, Chirine Zahar, for an unannounced annual inspection. The purpose of the inspection was explained. This facility is a school-aged after-school program. The program will be closed for summer on June 15 and resume operation in the new school year, beginning August 25. The facility operates in the Roosevelt Elementary school. During the school year, the days and hours of operations are Monday, Wednesday, Thursday, and Friday from 7 am – 9:00 am for the morning program and 3:15 pm – 6:00 pm for the afternoon program. Except for Tuesday, the afternoon program is 1:00 pm – 6 pm.

Along with the Director, LPA inspected the facility for health and safety hazards. A variety of age-appropriate furnishing and learning materials for children are available in the classroom. There are no pools, spas, or other bodies of water at the facility. The facility has multiple smoke detectors, a carbon monoxide detector, fully charged fire extinguishers, and a working telephone. All cleaning solutions, poisons, and other dangerous chemicals are stored in an area inaccessible to children. The facility is in good repair and free of any hazards with proper temperature and ventilation. All the bathrooms, toilets, and sinks are clean and well sanitized. All solid waste bins have a suitable tight-fitted lid on top, and the facility has a water dispensary readily available for children. The outdoor playground area is in good repair.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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 @ ROOSEVELT ELEMENTARY
FACILITY NUMBER: 414001605
VISIT DATE: 06/08/2022
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In today's inspection, LPA reviewed ten random samples of children's records and personnel files. According to the Director, the two teachers assigned to the Kindergarten and TK classrooms to come to the children's classroom and pick them up. The designated teacher for second–graders to fifth–graders will be positioned in the yard, and the children will meet the teacher there. The teacher will sign in all children, and a headcount will be conducted prior to entering the classroom. All children had a medical assessment, and required licensing forms were completed. All staff have record of a 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 once every other month, and the last drill was conducted on March 15, 2022. Records of all drills were adequately documented.

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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children's, personnel, and administrative records. 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: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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 @ ROOSEVELT ELEMENTARY
FACILITY NUMBER: 414001605
VISIT DATE: 06/08/2022
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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.

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. The Director can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

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 up-to-date Emergency Disaster Plan (LIC 610), Personnel Report (LIC 500), the Designation of Administrative Responsibility (LIC 308), and Incidental Medical Services (IMS) Plan to be sent to Licensing Office.

No deficiencies were cited today. An exit interview was conducted, and the report was reviewed with the Director, Chirine Zahar. Today's report, 6/8/2022, and site visit notice will be sent to the Director by email on 6/1\8/2022. Confirmation of receipt is required. 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: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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