414001605-1-22-2025-05-CC-MZAA-DD6VK9-20250122153000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414001605
Report Date: 01/22/2025
Date Signed: 01/22/2025 03:30:09 PM

Document Has Been Signed on 01/22/2025 03:30 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 @ ROOSEVELT ELEMENTARY		FACILITY NUMBER:	414001605
ADMINISTRATOR/ DIRECTOR:	ZAHAR, CHIRINE		FACILITY TYPE:	840
ADDRESS:	1151 VANCOUVER AVENUE		TELEPHONE:	(650) 863-1529
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY: 112	TOTAL ENROLLED CHILDREN: 112	CENSUS: 0	DATE:	01/22/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Director, Chirine Zahar		TIME VISIT/ INSPECTION COMPLETED:	03:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On January 22, 2025, at approximately 1:00 PM, Licensing Program Analyst (LPA) Melissa Zaragoza conducted an unannounced, annual inspection. LPA met with the director, Chirine Zahar, and explained the purpose of the visit. KCE Champions Roosevelt is a school age program. School age program is located inside the school grounds of Champions Roosevelt Elementary School. School age program has 5 classrooms licensed, RM # 20, RM #14, RM # 17 library, and the gym. Program currently operates in rooms 20, 14, and the library. The library is the 1^st grade class, room #14 is the TK and kinder class, and room #20 is 2^nd, 3^rd, 4^th and 5^th grade class. Hours of operation are Monday through Friday 7:00am to 8:30 am and 12:00pm to 6:00pm. Present during LPA's visit was the director, 0 school age children, and 3 teachers. School age program is operating within capacity limits and ratio during LPA's visit. LPA inspected facility, indoors and outdoors, for health and safety hazards. Classrooms includes a variety of equipment and materials that were in good condition. LPA observed classroom to have age-appropriate furniture, equipment, and materials. LPA observed no cleaning materials or poisonous items accessible to children in care, in classrooms. Per director, children to do not sleep while they are in the program. Children bring their water bottles from home and can refill their water bottles with the water filters inside the classrooms. Classrooms are equipped with a fully charged fire extinguisher and first aid kits. LPA observed a Carbon monoxide detector in the class. Carbon monoxide detector was tested during visit and was observed to be working. LPA was unable to test smoke alarm during visit. Smoke alarm is wired with the entire school building. Storage for children's belongings is inside the classrooms. LPA observed children to have their own individual cubby. Cubbies were observed to have each children’s individual name on it. (Continue Report on Page 2...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 @ ROOSEVELT ELEMENTARY	FACILITY NUMBER: 414001605
	VISIT DATE: 01/22/2025

NARRATIVE

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There are two bathrooms children can use. There is one bathroom inside the TK/Kinder class (library), and one bathroom inside the 1^st grade class (RM #14). Bathrooms have 1 sink and 1 toilet. Bathrooms for children were observed to be clean. The sinks and toilets were in working condition. LPA observed no cleaning solutions, poisons, and other hazardous materials for to be accessible to children in the bathroom.

Program provides a food service of morning snack and afternoon snack. Snacks are provided by the childcare center. Per director, children eat outside in the lunch area. Lunch area was observed to have benches for children to sit and eat. There are trash can bins for children to throw away their food once they are done eating. LPA observed roof sunshade installed, over the lunch benches for shade.

Facility has an outdoor space area. Outdoor was entirely enclosed and fenced. LPA observed outdoor play area to have a play structure with fake grass flooring, a basketball court, and a field space area for children. LPA observed play areas to be clean and maintained in good condition.

Program uses a form to sign in and out for their sign in/sign out system. Per director, staff members sign children in and out, and parents sign children out. LPA observed licensing posters and required documents to be properly collected. Program’s last disaster drills was conducted on November 19, 2024.

LPA reviewed 8 facility staff records. LPA reviewed 6 random children facility records which were complete and had all required documents. Children's records have emergency information on file. All staff on site have a current CPR/First Aid certification and mandated reporter certification. Staff records also include required immunizations that were made available for review.

Director was reminded all staff hired are required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KCE CHAMPIONS LLC @ ROOSEVELT ELEMENTARY	FACILITY NUMBER: 414001605
	VISIT DATE: 01/22/2025

NARRATIVE

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Director was reminded that all adults 18 and over, 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.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. 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). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Water quality has not been tested.

LPA's discussed the safe sleep regulations with director and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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 PIN 22-02-CCP. 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 are available at: https://www.ada.gov/resources/child-care-centers/.

Director was informed of the MyChildCarePlan.org website; 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.

Program was cited a Type B citation for not completing lead water testing requirement by due date of January 2023. Appeal Rights were provided.

Please see LIC 809-D for deficiencies cited today.

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

Exit interview conducted and report was reviewed with the director, Chirine Zahar.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/22/2025 03:30 PM - It Cannot Be Edited

Created By: Melissa Zaragoza On 01/22/2025 at 02:53 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KCE CHAMPIONS LLC @ ROOSEVELT ELEMENTARY	FACILITY NUMBER: 414001605
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.16(a)(1)

Lead Testing

(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not completing lead testing by January 1, 2023 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Facility plans to test for lead water, once facility has tested, they will submit proof of testing to the LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Marie Rodriguez

LICENSING EVALUATOR NAME:

Melissa Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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