414001605-3-20-2026-05-CC-KKRN-DSD2AF-20260320171327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414001605
Report Date: 03/20/2026
Date Signed: 03/20/2026 05:13:33 PM

Document Has Been Signed on 03/20/2026 05:13 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: 98	CENSUS: 42	DATE:	03/20/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:30 PM
MET WITH:	Chirine Zahar and /Karen Mayen		TIME VISIT/ INSPECTION COMPLETED:	05:30 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 March 20, 2026 at approximately 3:30PM Licensing Program Analyst (LPA) Katie Krenn arrived at the facility for an unannounced case management visit regarding an unusual incident that the facility self-reported. Upon arrival, LPA met with a site director, Chirine Zahar (D1) and explained the purpose of the day's visit. In addition to D1, LPA observed four staff supervising 42 children. LPA observed that the facility was operating within its capacity and ratio requirements during today's visit. All staff present have received criminal background clearance from the department of social services and are associated with this facility on Guardian. 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 five 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 1st grade class, room #14 is the TK and kinder class, and room #20 is 2nd, 3rd, 4th and 5th grade class. Hours of operation are Monday through Friday 7:00AM to the morning school bell and from the afternoon school bell to 6:00PM. LPA observed that all required postings—including the Facility License, Notification of Parents’ Rights (PUB 393), Personal Rights (LIC 613A), Child Passenger Restraint System (PUB 269), Emergency Disaster Plan (LIC 610), and Earthquake Preparedness Checklist—were displayed and visible to families in the classroom where children are picked up. continued on page 2

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026

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

FACILITY NAME: KCE CHAMPIONS LLC @ ROOSEVELT ELEMENTARY	FACILITY NUMBER: 414001605
	VISIT DATE: 03/20/2026

NARRATIVE

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LPA interviewed the site director and two teachers that were present on the day of the incident and overheard some of the conversations. Per the staff there was incident involving two children. At pickup, D1 was explaining to a parent of one of the children what happened. Everyone that LPA interviewed observed a language barrier between the parent and D1. Per the staff, the parent did come to understand what D1 was communicating and after that the parent left with their child. Approximately, 10-20 minutes later the parent returned with their child. Staff observed that the parent raised their voice. D1 and the parent were unable to come to an agreement and the parent requested to speak with D1’s supervisor, Melissa Jostedt (D2).

LPA was not able to interview the parent or D2 as they were not present during LPA's visit. Per the report submitted by D2, D2 was able to connect with the parent.

Facility Representative 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.

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/.

To improve the quality and value of the 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.

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

Exit interview conducted and report was reviewed with the Lead Teacher, Karen Mayen.

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Katie Krenn
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026

LIC809 (FAS) - (06/04)

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