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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004699
Report Date: 06/08/2022
Date Signed: 06/08/2022 12:41:20 PM

Document Has Been Signed on 06/08/2022 12:41 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 @ WASHINGTON ELEMENTARY (SA)FACILITY NUMBER:
414004699
ADMINISTRATOR:NGUYEN, KRISTYFACILITY TYPE:
840
ADDRESS:801 HOWARD AVENUETELEPHONE:
(650) 906-2506
CITY:BURLINGAME,STATE: CAZIP CODE:
94010
CAPACITY: 109TOTAL ENROLLED CHILDREN: 109CENSUS: 0DATE:
06/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Kristy Nguyen and Sharon PfeifferTIME COMPLETED:
12:45 PM
NARRATIVE
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On June 8, 2022, Licensing Program Analysts (LPA) Van made an unannounced Case Management inspection and met with Site Director Kristy Nguyen and Program Manager Sharon Pfeiffer. The purpose of the inspection was to follow up on an unusual incident at the Center that the Department received on May 25, 2022. The Facility self-reported an incident where C1 left the school and was found outside a locked school gate.

According to Director, the incident occurred during the outdoor play at approximately 3:56 PM. Three teachers were supervising 28 children. Per Director, C1 left the school and exited through the main school gate located on the opposite side of the Preschool program portable, roughly a football field's length. C1 walked approximately a block from the school main gate and was found by another staff by the ramp going to the Preschool portable classrooms.

Based on the interview and the incident report received on May 25, 2022. regarding the above incident, it was found that supervision was absent when the child was left the site alone and walked outside of the school without the teacher's knowledge. A $500 civil penalty was assessed today for the absence of supervision.
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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Document Has Been Signed on 06/08/2022 12:41 PM - It Cannot Be Edited


Created By: Brendon Van On 06/08/2022 at 12:08 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 @ WASHINGTON ELEMENTARY (SA)
FACILITY NUMBER: 414004699

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2022
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision...children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1).
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Immediate action was taken to correct this incident. On the following day, May 26, 2022, Director had all staff training on supervision, accountability, and tracking policies, including scan & name and face check. Training materials were provided to LPA during the visit.

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This requirement is not met, as evidenced by the interview and facility incident report. The staff failed to provide adequate supervision, which allowed C1 to leave the Facility and walk outside of the school without the staff's knowledge. This poses an immediate health and safety risk to children in care. A CIVIL PENALTY OF $500 WAS ASSESSED TODAY.
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POC cleared on 6/8/2022

A follow-up Informal Meeting is to be scheduled for a later date.

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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:Garfield Leung
LICENSING EVALUATOR NAME:Brendon Van
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my 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 @ WASHINGTON ELEMENTARY (SA)
FACILITY NUMBER: 414004699
VISIT DATE: 06/08/2022
NARRATIVE
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A Type "A" violation was issued today. The Facility is advised to provide a copy of the Evaluation Report and the Type "A" Deficiency cited to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. This report will be maintained in the facility file and made available for public review three years after the thirty-day posting requirement has been met. Today's report, June 8, 2022, and notice of site visit will be sent to the Director by email by the close of business on June 8, 2022. Confirmation of receipt is required. LPA informed the Director that the site visit notice and deficiency page 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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