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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005067
Report Date: 08/27/2025
Date Signed: 08/27/2025 04:39:41 PM

Document Has Been Signed on 08/27/2025 04:39 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 @ ALLEN ELEMENTARY SCHOOLFACILITY NUMBER:
414005067
ADMINISTRATOR/
DIRECTOR:		SAUCEDA, CYNTHIAFACILITY TYPE:
840
ADDRESS:875 WEST ANGUS AVENUETELEPHONE:
(650) 255-0420
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: 48DATE:
08/27/2025
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Evan BernsteinTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 8/27/2025, at 2:05 PM, Licensing Program Analysts (LPAs) Wadhwa and Ly arrived at the facility to conduct an unannounced, case management inspection for an increase of capacity and room addition.
LPAs met with Site Director, Evan Bernstein, and explained the purpose of the visit. Present at the facility today are 48 school-age children with 7 staff (including the Site Director). The program currently operates Monday through Friday 7:00 AM to 8:00 AM and 1:00 PM to 6:00 PM.

Facility is currently licensed to operate out of Room #106 and the Library of the Allen Elementary School and to serve 28 children. Facility has requested to continue using Room#106 and the Library with the addition of the Multi-Purpose Room and to increase capacity from 28 to 120 students. Fire clearance was obtained on 6/24/2025.

The school age program is exempt from requirements for indoor and outdoor space square footage, fencing, and toilet/sink ratios. No measurements were taken during the inspection.

LPAs inspected the Multipurpose Room for health and safety hazards. LPAs observed multiple smoke detectors, and a fire extinguisher located inside of the room. Facility ensures solutions, poisons, and other chemicals that are dangerous to children are stored inaccessible to the children in care.

At 2:05 PM LPAs observed the program to be operated out of the Multipurose Room. Per Site Director, the facility has been operating out of the Multi-purpose room since 8/21/2025, prior to receiving approval from Licensing. A Type B citation will be issued in accordance with the California Code of Regulations, Title 22, see LIC 809D.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2025
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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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 @ ALLEN ELEMENTARY SCHOOL
FACILITY NUMBER: 414005067
VISIT DATE: 08/27/2025
NARRATIVE
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At 2:45 PM, based on observation, interviews and file review, LPAs confirmed the facility is operating overcapacity. Facility is currently licensed for 28 students but there were 48 students present during today’s visit. A Type A violation has been issued for over capacity on this day in accordance with the California Code Regulations, Title 22, see LIC809D.

LPAs observed the Multi-purpose Room to be added, to be clean, equipped with age-appropriate activities, materials and furniture. LPAs observed furniture to be in good repair and free of any hazards. The Multi-purpose Room is equipped with school district fire alarm system.

The program has requested the use of the following restrooms: Girls Room and Boys Room located in the Lower Hallway and the Girls Room and Boys Room located in the Multipurpose Room. LPAs observed restrooms to be clean and in proper condition. Restrooms allow for individual privacy.

Based on fire clearance approval and LPA inspection, room addition of the Multi-Purpose Room is being approved for use as of today: 8/27/2025. On this day, LPAs Wadhwa and Ly have approved the requested capacity increase from 28 to 120 students.

The program is currently licensed to use the entire fully fenced outdoor area. LPAs inspected the outdoor area and observed it to be in good repair.

The program uses paper sign in/sign out sheets, and children are signed into the program by the Champions staff. The children are signed out by their authorized representatives with written signatures. LPAs observed licensing posters and required documents to be properly posted.

Supervisors are aware enrolled children using the playgrounds will always be supervised and monitored. LPAs did not observe any pools, spas or bodies of water on school district site.

Supervisor was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
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NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
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 @ ALLEN ELEMENTARY SCHOOL
FACILITY NUMBER: 414005067
VISIT DATE: 08/27/2025
NARRATIVE
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The facility was cited for deficiencies today under CCR, Title 22, Division 12.

LPAs informed the Site Director to provide a copy of this licensing report (8/27/2025) that documents any Type A citation(s) 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 (LIC9224), or other written statement, must be placed in the child’s file for verification.

A notice of site visit was given and must remain posted for 30 days . Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Site Director, Evan Bernstein. A copy of this report and appeal rights were provided to the Site Director. Site Director's signature confirm receipts of these reports.
NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Ruhi Wadhwa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2025 04:39 PM - It Cannot Be Edited


Created By: Ruhi Wadhwa On 08/27/2025 at 03:43 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 @ ALLEN ELEMENTARY SCHOOL
FACILITY NUMBER: 414005067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2025
Section Cited
CCR
101161(a)

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101161 Limitations on Capacity (a) A licensee shall not operate a child care center....
This requirement was not met as evidenced by
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A request for change of capacity from 28 to 120 students was initiated on 6/13/2025. As of today, this request has been approved.


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At 2:45 PM, based on observation, interviews and file review, LPAs confirmed the facility is operating overcapacity. Facility is currently licensed for 28 students but there were 48 students present during today’s visit.
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Deficiency has been cleared today and a letter of Clear Deficiency has been provided to the Site Director.

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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.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Ruhi Wadhwa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2025 04:39 PM - It Cannot Be Edited


Created By: Ruhi Wadhwa On 08/27/2025 at 03:57 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 @ ALLEN ELEMENTARY SCHOOL
FACILITY NUMBER: 414005067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2025
Section Cited
CCR
101212(c)

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101212 Reporting Requirements
(c)The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce ...
This requirement was not met as evidenced by
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A request for room addition was initiated on 6/13/2025. LPAs advised Site Director that prior to using unapproved spaces, Licensing should be notified so that proper approvals are obtained before use. As of today, the requested room addition have been approved.
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At 2:05 PM LPAs observed the program to be operated out of the Multipurose Room. Per Site Director, the facility has been using the Multi-purpose room since 8/21/2025.
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Deficiency has been cleared today and a letter of Clear Deficiency has been provided to the Site Director.


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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.
Marie Rodriguez
NAME OF LICENSING PROGRAM MANAGER:
Ruhi Wadhwa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2025


LIC809 (FAS) - (06/04)
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