414005017-8-3-2023-05-CC-CQUO-CUCRKC-20230803130520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414005017
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:05:26 PM

Document Has Been Signed on 08/03/2023 01:05 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 @ BAYSIDE ACADEMY		FACILITY NUMBER:	414005017
ADMINISTRATOR:	SAMBATH, ELIZABETH		FACILITY TYPE:	840
ADDRESS:	2025 KEHOE AVENUE		TELEPHONE:	(510) 303-0029
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	08/03/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Melissa Jostedt & Elizabeth Sambath		TIME COMPLETED:	01:15 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 August 3, 2023 at approximately 11:00am, Licensing Program Analyst (LPA) Catrina Quimbo, conducted a pre-licensing inspection. LPA met with area manager, Melissa Jostedt, and site director, Elizabeth Sambath. The applicant is requesting a school age license for 60 children (Kindergarten to 8th grade). The facility will operate Monday through Friday 12:30pm to 6:00pm. The Champions after school program will operate at Bayside STEM Academy site of San Mateo Foster City school district in Classrooms #1 and #48 only. The designated site director will be Elizabeth Sambath. The facility was inspected, indoors and outdoors, for health and safety hazards. The school age program is exempt from requirements for indoor and outdoor square footage, fencing, and toilet/sink ratios. No measurements were taken during LPA's visit. Indoors: The main classroom for Champions will be Classroom #1. Champions will also be licensed to utilize Classroom #48. Classroom is equipped with appropriate furniture that is in good working condition. Per school district, classroom is equipped with a dual smoke/carbon monoxide detector. LPA observed smoke detector in classroom's high ceilings. Entire facility has a fire alarm system that is installed and implemented by school district. Classroom is equipped with a fully charged fire extinguisher and a fully stocked first aid kit. Medications with required documentation will be stored in main classroom #1. Champions plans to use mobile carts that will be transferred indoors and outdoors that include fully stocked first aid kits. All toxins and hazardous items will be stored in locked cabinets, inaccessible to children. Isolation for a sick child will be in the classroom, separate from other enrolled children. Champions will have access to two sets of bathrooms on site: between Classrooms #26-33 and Classrooms #11-18. Restrooms were observed to be clean and in proper working condition. Restrooms allow for individual privacy. Program will use school district garbage cans and bines that will be disposed of daily by school district site's janitorial services. (Continue Report on Page 2...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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 @ BAYSIDE ACADEMY	FACILITY NUMBER: 414005017
	VISIT DATE: 08/03/2023

NARRATIVE

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Program will provide dry, afternoon snacks only. Per site director and area manager, food will be stored in a cabinet that does not contain toxins or poisons. Per site director and area manager, toxins and poisons will be stored in a separate locked cabinet located in classroom #1. Water is accessible to enrolled children with multiple refillable water stations.

Outdoors: The entire outdoor area of the school is enclosed by a fence that is at least four feet tall. Champions program has access to entire outdoor area that includes black tops, soccer field and two playgrounds. LPA observed playground #1 to be fully enclosed and fenced for children ages 2 years to 5 years old. Playground #2 is for children ages 5 years to 12 years old. Playgrounds include play structures that were observed to have resilient padding underneath. LPA observed playground to be clean, safe and free of any loose articles or materials.

Site director is aware enrolled children using the playground will always be supervised and monitored. Site director is aware enrolled children must always be supervised going to and and from restroom, playground area and classrooms.

Site director is aware disaster drills are conducted monthly and must be properly logged. Licensing documentation and posters were observed to be properly posted and made available for review in classroom #1. Children will be signed in and out of program with authorized representatives' written signatures. Site director is aware sign in/out sheets must be made available for review.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) tollfree 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, available at: http://www.ada.gov/childqanda.htm.

LPA reviewed with applicant, the LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

The requirement for Lead Water Testing was discussed (H&S Code 1597.16). Applicant was reminded a facility licensed after July 1, 2022, must have their water fixtures tested for lead 180 days after licensure and every 5 years thereafter. LPA advised applicant to review PIN 21-21-CCP.
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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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 @ BAYSIDE ACADEMY	FACILITY NUMBER: 414005017
	VISIT DATE: 08/03/2023

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Facility representative was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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.

Facility representative was informed of the MyChildCarePlan.org site, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/ subscribe and select the Child Care option to receive email communication.

Prior to recommended licensure, following must be completed:
-Resubmission of documents indicated on Notice of Incomplete Application (LIC184C).
-LPA's review and approval of documents resubmitted.

Exit interview conducted and report was reviewed with site director, Elizabeth Sambath.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

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