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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004845
Report Date: 04/24/2025
Date Signed: 04/24/2025 06:25:52 PM

Document Has Been Signed on 04/24/2025 06:25 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 @ SACRED HEART SCHOOLSFACILITY NUMBER:
414004845
ADMINISTRATOR/
DIRECTOR:		SALAH, AMANYFACILITY TYPE:
840
ADDRESS:50 EMILIE AVENUETELEPHONE:
(650) 223-1804
CITY:ATHERTONSTATE: CAZIP CODE:
94027
CAPACITY: 60TOTAL ENROLLED CHILDREN: 73CENSUS: 9DATE:
04/24/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Director, Consuelo RosasTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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On April 24th, 2025 at approximately 1PM, Licensing Program Analysts (LPAs) Tapia-Mandujano and Olguin-Leon conducted an unannounced annual inspection. LPA met with new Director, Consuelo Rosas and explained the purpose of the inspection. Present in the facility are Director and 1 staff supervising a total of 9 school age children. All adults working in the facility are fingerprint cleared and are associated. Facility is currently operating within teacher to child ratio on this date.

Facility is located on Sacred Heart Schools Campus. Facility operates Monday-Friday from 3pm-6pm Year-round program. Facility is licensed to operate in Room 606, 608, and school gymnasium.

On December 5th, 2023, LPA Tapia-Mandujano conducted an inspection, where it was observed that facility was operating In Room #4 that is a classroom that is not approved by the Department. Facility was also comingling preschool age children with school age children in Room #4. During today’s inspection, LPAs observed that School age children continued to use Room #4 and were still comingling with Preschoolers. Director separated the School age children to no longer comingle and placed School Age children in Room #2. Type A citation was cited.

LPAs conducted a health and safety inspection and observed classroom #2 and #4 to be clean and equipped with age-appropriate toys and materials. Storage for children's belongings are located inside the classroom. LPA observed facility has an installation of a fire alarm system throughout the building as well as a fully charged, fire extinguisher in the classrooms. The building has a smoke detector installed as well as emergency kits with first aid materials and emergency contact information. Medication is stored in Room #4, inaccessible to enrolled children and maintained with proper documentation. LPA observed that all children present were signed in by staff and will be signed out by authorized person. Facility has license documentation and information properly posted and available for review in Room #4.

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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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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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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Document Has Been Signed on 04/24/2025 06:25 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 04/24/2025 at 05:02 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 @ SACRED HEART SCHOOLS
FACILITY NUMBER: 414004845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101212(c)
Reporting Requirements
(c) The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and inspections on 12/05/23 and 4/24/25, the licensee did not comply with the section cited above as the facility did not notify the department that they lost control of Rooms 606 and 608. Facility also did not notify the department that they will use Room #4 that is not approved for School age program. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Facility will develop a plan on how they will comply with licensing regulations. Facilities plan should include what rooms are planned to be used, schedule if there will be a rotaion of classrooms, and submit an application to approve the new rooms.

Office meeting will be scheduled for a later date.
Type A
Section Cited
CCR
101161(a)
(a) A licensee shall not operate a child care center beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, and inspections on 12/05/23 and 4/24/25, the licensee did not comply with the section cited above as the facility was operating in Room #4 that is not approved by department. Facility was also comingling preschool age children with school age children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Facility seperated the School age children from preschool age children as of today. School age children were moved to Room #2.

Facility will also submit an application to approve the designated rooms for School age program with an updated operation plan with details on what rooms will be used, including a rotation schedule if needed.

Office meeting will be scheduled for a later date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Leslit Tapia-Mandujano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 06:25 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 04/24/2025 at 05:02 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 @ SACRED HEART SCHOOLS
FACILITY NUMBER: 414004845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025

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
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Based on interview and record review, the licensee did not comply with the section cited above as the deparment has not received documentation to prove that the building was built after 2010, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Facility must submit proof to department to prove that the building was built after 2010 therefore not requiring them to be tested for lead.

Proof must be sumbited via email to LPA Olguin-Leon by May23rd, 2025.
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as director stated that they have not conducted an emergency drill since she onboarded and the last one that was documented was from last year, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Facility will conduct an emergency drill with children enrolled.

Facility will submit written documentation of via email to LPA Olguin-Leon by May 9th, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Leslit Tapia-Mandujano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 06:25 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 04/24/2025 at 05:02 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 @ SACRED HEART SCHOOLS
FACILITY NUMBER: 414004845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as there was a staff that did not renew the mandated reporter training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Staff will renew their mandated reporter training.

Facility will submit proof of completion via email to LPA Olguin-Leon by May 9th, 2025.
Type B
Section Cited
CCR
101212(b)
(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the facility did not notify the department of the change of director which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2025
Plan of Correction
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Facility will submit a change of director packet.

Director packet will be mailed in or brought in to the office with original signatures by May 9th, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Leslit Tapia-Mandujano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


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 @ SACRED HEART SCHOOLS
FACILITY NUMBER: 414004845
VISIT DATE: 04/24/2025
NARRATIVE
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All poisons, cleaning solutions and hazardous materials are stored inaccessible to children in off limit areas or facility high shelves. Facility offers one snack. Menus are posted in Room #4. Facility offers water in each classroom that is refilled through a water Britta that is filled by Room #4 faucet. Water is available to children indoors and outdoors. Outdoor area appears to be clean and orderly. There are a variety of outdoor equipment that are in good working condition.

LPA reviewed facility records that included 5 children's records and 2 staff records. LPA observed children's and staff's records to be complete. At least one staff have an up-to-date CPR & First Aid certificate. Staff do not have up to date Mandated Reporter Certificate. Type B citation was cited. Per Director, they have not done an emergency drill since she onboarded and the ast emergency drill was documented since last year. Type B citation was cited. Emergency drills must be conducted at least once every six months and are properly logged and documented.

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.

Facility was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

Director is aware that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed the completion certificate on file. LPA encourages the director to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates.

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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
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 @ SACRED HEART SCHOOLS
FACILITY NUMBER: 414004845
VISIT DATE: 04/24/2025
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.

LPA referred Director to the department website for lead: Lead Toxicity Prevention and Water Testing Information.

Per Director, facility building was built after 2010. Department has not received any documentation to prove that it was built after 2010, therefore a Type B citation will be cited.

This facility provides Incidental Medical Services – IMS. LPAs 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-carecenters/.

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.

LPA Tapia-Mandujano informed director, Consuelo Rosas that this report dated April 24th, 2025 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health and safety of children in care.

Also, LPA Tapia-Mandujano informed director, Cosuelo Rosas to provide a copy of this licensing report dated April 24th, 2025 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Based on today's inspection, deficiencies were observed, according to California Title 22, Health and Safety Code of Regulations.

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

Exit interview conducted and report was reviewed with Director, Consuelo Rosas.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Leslit Tapia-Mandujano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
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