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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004845
Report Date: 11/02/2021
Date Signed: 11/02/2021 05:34:35 PM

Document Has Been Signed on 11/02/2021 05:34 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 @ SACRED HEART SCHOOLSFACILITY NUMBER:
414004845
ADMINISTRATOR:SALAH, AMANYFACILITY TYPE:
840
ADDRESS:50 EMILIE AVENUETELEPHONE:
(925) 457-7138
CITY:ATHERTONSTATE: CAZIP CODE:
94027
CAPACITY: 60TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/02/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melissa JostedtTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Glenn Schnell met with Applicant Melissa Jostedt today for a pre-licensing inspection. This inspection included a technical assistance inspection for COVID-19 guidance and support. The applicant is requesting 60 children (ages 5 years old to 14 years old). The facility will operate Monday - Friday; 6:00 AM to 7:30 AM and 3:15 PM to 6:00 PM. When children are not in session in Sacred Heart Schools Program, they will be in attendance at KCE Champions program. This will be primarily during holiday breaks and other school closures or early release. The program has entered into a contract with Sacred Heart Schools to provide extended day care to Sacred Heart School's Elementary School Program. The designated director/site supervisor for the facility is Amany Salah. The facility was inspected today, indoor and outdoor, for health and safety hazards and measured to calculate capacity.
Indoor: The rooms to be used for the school-age program are: 606, 608 and the gymnasium. Applicant understands that when room 608 or 606 is being used by the KCE preschool program, that the school age program may not use the rooms. This program is exempt from the indoor square footage requirements and there is a capacity letter on file verifying that the rooms used will hold the requested capacity of 60.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Glenn A Schnell
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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 @ SACRED HEART SCHOOLS
FACILITY NUMBER: 414004845
VISIT DATE: 11/02/2021
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The indoor space for children is observed today to be clean and all furnishing, toys and equipment observed to be safe and in good condition. There is storage space for children's personal belongings located in the classroom. The facility is equipped with a fire extinguisher, smoke and carbon monoxide detectors, food prep/kitchen area (in room 606) with a refrigerator, stove, and dishwasher. Garbage cans with tight-fitting lids, first aid and emergency supplies were also observed. The facility is adequately ventilated and free of insects and bugs.
The program provides two snacks daily and parents will provide lunch when children are in attendance a full day. Only disposable products will be used for food service. Snack foods will be stored in room 606 separately from any cleaning products or other hazards. Medications will be stored in room 608 inaccessible to the children; there is a refrigerator in room 608 for refrigerated medications.
There are sinks for hand washing located in room 606 and 608. There are toilets for the children located in room 608 and this program will share additional bathrooms located on the school campus. This program is exempt from the sink and toilet to child ratio of 1:15 because it is a school age program operating on a functioning school site and the classrooms that are being used are owned by Sacred Heart Schools. The bathrooms are observed to be clean and with no health and safety hazards. The bathroom allow for individual privacy. The sinks accessible to children do not deliver warmer than 120 degrees. The program will provide a pitcher with water and cups for children to drink water indoors and children also bring their own water bottles.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Glenn A Schnell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 @ SACRED HEART SCHOOLS
FACILITY NUMBER: 414004845
VISIT DATE: 11/02/2021
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All toxins and other hazardous items will be stored in a locked cabinet or room and will be inaccessible to children. Isolation room for a sick child will be outside of the classrooms, weather permitting or in an area of the classroom away from the other children. The staff bathroom will be used for the child until the parent arrives for pick up. Sign-in/Sign out of the children will be completed parents at drop off and pick up, however, when children leave to attend school and arrive back after school, staff will sign children in and out.
Outdoor: This program is exempt from outdoor square footage because the program is located on a functioning school site. The outdoor space to be used is located on the school campus and is The kinder playground, the blacktop and basketball court, the play structure/grassy field outside of gymnasium. The Sacred Heart School campus is enclosed by at least a four foot fence and the area to be used by this program is observed to be clean, safe and equipped with toys and equipment for children. Supervision of the children outdoors was discussed in detail due to the size of the campus. The program plans to use orange cones to mark areas to show children what the boundaries are of the outdoor space are accessible for use. There is sufficient resilient material, wood chips located under climbing structures. Pitchers of water and cups will be used to have access to drinking water and children will also have their own water bottle. Shade for children is provided. No bodies of water were observed today.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Glenn A Schnell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 @ SACRED HEART SCHOOLS
FACILITY NUMBER: 414004845
VISIT DATE: 11/02/2021
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The following items were reviewed as part of today's visit: Record keeping for staff, children and facility records, Care and Supervision of the Children, Child Discipline Procedures-talking and redirection, Emergency Evacuation Procedures, Medication Policies, Isolation of Sick Children, Food Service, Transportation-none provided, Parents Rights, sign in/sign out procedures, and Reporting Requirements.

The facility will conduct monthly disaster drills and a log will be maintained for review upon request. The requirement for the testing of lead in the water was discussed (H&S Code 1597.16). LPA informed the director/licensee to review Provider Information Notice 21-21-CCP (dated 7/28/21) for directives and regulations regarding obtaining a test of the water for lead, and how that information is to be documented and reported to Community Care Licensing. The requirement for testing must be met by January 2023.

This facility will provide Incidental Medical Services – IMS. LPA reviewed storage area for medication and equipment/supplies, and reviewed forms that will be used. 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: Ali Zebila
LICENSING EVALUATOR NAME: Glenn A Schnell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 @ SACRED HEART SCHOOLS
FACILITY NUMBER: 414004845
VISIT DATE: 11/02/2021
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LPA Schnell reviewed the COVID-19 self assessment guide and required postings with the applicant today. Applicant was informed that access to available Personal Protective Equipment (PPE) may be available through the local child care resource and referral agency.
Report was reviewed and signed by Applicant, Melissa Jostedt. Today’s report, 11/2/21, will be sent to Melissa Jostedt at mjostedt@discoverchampions.com by close of business, 11/2/21. Confirmation of receipt is required.
LPA Schnell will recommend licensure of this facility for a capacity of 60 children once the following is received:
-Approved Fire Clearance (STD 850)
-Pesticides Training & 8 hours Preventative Health Training/Lead Poison training for Amany
-Updated Personnel Policies
-Monthly Operating Statement (LIC 401)
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Glenn A Schnell
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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