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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004698
Report Date: 01/28/2025
Date Signed: 01/28/2025 11:10:28 AM

Document Has Been Signed on 01/28/2025 11:10 AM - 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 @ WASHINGTON ELEMENTARY (PS)FACILITY NUMBER:
414004698
ADMINISTRATOR/
DIRECTOR:		NAVARRO, JACQUELINEFACILITY TYPE:
850
ADDRESS:801 HOWARD AVENUETELEPHONE:
(650) 906-2506
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
01/28/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lead teacher, Natalia BenitezTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On January 28, 2025, at approximately 9:00 AM, Licensing Program Analyst (LPA) Melissa Zaragoza conducted an unannounced, annual inspection. LPA met with the lead teacher, Natalia Benitez, and explained the purpose of the visit.

KCE Champions Washington is a preschool age program. Preschool program is located In the school grounds of Washington Elementary School. Preschool program operates one classroom only. Classroom is considered, Champions Preschool program classroom.

Hours of operation are Monday through Friday 8:00am to 5:00pm. Present during LPA's visit was 2 lead teachers, and 8 preschool age children. All teachers in the classroom have background fingerprint clearance on file. Program is operating within capacity limits and ratio during LPA's visit.

LPA inspected facility, indoors and outdoors, for health and safety hazards. Classroom includes a variety of toys and materials that were in good condition. LPA observed classroom to have age-appropriate furniture, equipment, and materials. LPA observed cleaning materials to be stored in a locked closet, inaccessible to children in care.

Per lead teacher, children sleep in mats. Mats were observed to be stored in the classroom. Per lead teacher, children’s parents provide the blankets, and the childcare center provides the sheets. Per lead teacher, sheets and blankets are taken home every Friday for wash. Per lead teacher, mats are wiped down weekly.

The classroom is equipped with a fully charged fire extinguisher and first aid kit. LPA observed Carbon monoxide detector. Carbon monoxide detector was tested during visit and was observed to be working. LPA observed smoke detector in the classroom. LPA was unable to test smoke alarm due to smoke alarm being wired to the entire school building. Storage for children's belongings is in classrooms. Children's cubbies are labeled with children's individual names.

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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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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 @ WASHINGTON ELEMENTARY (PS)
FACILITY NUMBER: 414004698
VISIT DATE: 01/28/2025
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There is one bathroom in the classroom for the children. Bathroom for children was observed to be clean. Bathroom has 2 toilet and 2 sinks. The sinks and toilet were in working condition. Bathroom was equipped with appropriate sanitation products. LPA observed bathroom to have trash can bins with a tight fitted lid. LPA observed no cleaning solutions, poisons, and other hazardous materials for to be stored in bathroom. LPA did not observe any accessible poisons or chemicals in classroom.

Program provides snacks only, when necessary. Per lead teacher, children bring lunch and snack from home. LPA observed children to store their lunch bags in their individual cubbies. LPA observed children’s individual cubbies to be labeled with their names on it. Per lead teacher, children have the option to eat food that is prepared from the school district.

Outdoor area is entirely enclosed and fenced. LPA observed outdoor play area to have a roof top sunshades installed for shade. LPA observed play area to have fake grass flooring. Outdoor area was also observed to have black top flooring, a basketball court, and a play structure. LPA observed toys and material to be in good conditions. Per lead teacher, children bring water bottles from home, and refill them in the classroom. LPA observed filtered water in class.

Program uses a form for parents to sign in and out for their sign in/sign out system. Children were properly signed in during LPAs’ visit. LPA observed licensing posters and required documents to be properly posted inside the classroom. Program’s last disaster drills was conducted on January, 2025.

LPA reviewed 2 facility staff records. LPA reviewed 6 random children facility records which were complete and had all required documents. Children's records have emergency information on file. All staff on site have a current CPR/First Aid certification. LPA reminded lead teacher; mandated reporter training must be renewed every 2 years for all staff working with children. Staff records also include required immunizations that were made available for review.

Director was reminded all staff hired are required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

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

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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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 @ WASHINGTON ELEMENTARY (PS)
FACILITY NUMBER: 414004698
VISIT DATE: 01/28/2025
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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.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

Water quality was tested on 03/15/2023 and results complied. Lead water was tested after the due date of 1/1/23.

LPA's discussed the safe sleep regulations with director and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility provides Incidental Medical Services – IMS. LPA 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-care-centers/.

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.

Program was cited a Type B citation for not completing lead water testing requirement by due date of January 2023. Appeal Rights were provided. Facility's lead levels were within the 5.5ppb threshold, therefore deficiency cited today will also be cleared today.

Please see LIC 809-D for deficiencies cited today.

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

Exit interview conducted and report was reviewed with the lead teacher, Natalia Benitez.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2025 11:10 AM - It Cannot Be Edited


Created By: Melissa Zaragoza On 01/28/2025 at 10:50 AM
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 (PS)
FACILITY NUMBER: 414004698

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

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 observation and record review, the licensee did not comply with the section cited above by not completing lead testing by January 1, 2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Facility tested water fixtures on March 15, 2023, after the lead testing requirement due date. Water fixtures tested are below the 5.5 ppb threshold. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


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