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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004844
Report Date: 11/02/2021
Date Signed: 11/02/2021 05:35:33 PM

Document Has Been Signed on 11/02/2021 05:35 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:
414004844
ADMINISTRATOR:SALAH, AMANYFACILITY TYPE:
850
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:
10:15 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 2 years to entry into first grade). 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 Preschool 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 licensed preschool 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: There are six classrooms that will be used for the program (Rooms 1-4 and rooms 606 and 608). Total useable indoor square footage is 4906.802 sq ft divided by 35 sq ft equals 140 children. When rooms 606 and 608 are not being used by the program, the maximum indoor capacity is 3376.248 sq, ft. or 96 children. 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.
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: 414004844
VISIT DATE: 11/02/2021
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Applicant understands that when room 608 is being used by the KCE school age program, that the school age program may not use the room. There is storage space for children's personal belongings and cots to be utilized for napping children. Parents will provide a blanket and the program will provide a sheet for the child, bedding will sent home to be laundered weekly. Cots will be cleaned at least weekly or more often if needed. Children will be signed in and out by manually. 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. The indoor space is equipped with a fire extinguisher, smoke and carbon monoxide detectors, separate kitchen area where snack food is stored, garbage cans with tight-fitting lids, first aid and emergency supplies. The facility is adequately ventilated and free of insects and bugs. The program provides two snacks daily and parents will either provide lunch when the program operates a full day. Only disposable products will be used for food service.

Snack foods will be stored in the kitchen area in room 606 separately from any cleaning products or other hazards. Medications will be stored in the refrigerator (lock box in refrigerator) in room 608 or in the staff bathroom in room 608 and will be inaccessible to the children. There are 4 toilets ( 60 capacity) and 8 sinks (120 capacity) accessible for children's use. Bathrooms are located in rooms 1-4 . The bathrooms were observed to be clean and with no health and safety hazards.
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: 414004844
VISIT DATE: 11/02/2021
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Sinks accessible to children deliver water that is no warmer than 120 degrees. The program will provide a pitcher with water and cups for children to drink water indoors. Children will also bring water bottles from home each day. Any toxins/poisons will be locked, and cleaning supplies and other hazards will be inaccessible to children. Isolation of ill children will be located either in a corner of the classroom or directly outside the classrooms, weather permitting. The staff bathroom located in room 608 will be used for an ill child.

Outdoor: The outdoor area measures 17250 sq. ft allowing for a total of 230 children. The outdoor space is the same space the preschool/pre-kinder children will use when they are in attendance at Sacred Heart Schools program. The outdoor area to be used is enclosed by at least a four foot fence and observed to be clean, safe and equipped with toys and equipment for children. Resilient material located under climbing applicable climbing structures is wood chips. There is pitcher and cups to allow children access to drinking water outside. Children will also have their own water bottles from home. Shade for children will be provided by shade structures.
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: 414004844
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- staff will talk with the children and use redirection, positive behavior support, Emergency Evacuation Procedures, Medication Policies, Isolation of Sick Children, Napping Requirements, Food Service, Transportation-none provided, Parents Rights, and Reporting Requirements. Required postings were observed during today's inspection. Facility will conduct monthly disaster drills and a log will be maintained for review upon request. The fire inspection was conducted, and approval was received on 10/18/2020. The requirement for the testing of lead in the water was discussed (H&S Code 1597.16). LPA advised the applicant 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.
Applicant 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. This facility will provide Incidental Medical Services – IMS. LPA reviewed storage area for medication and equipment/supplies, and reviewed forms that will be used.
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)
Page: 3 of 5
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: 414004844
VISIT DATE: 11/02/2021
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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

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:
-Pesticides Training & 8 hours Preventative Health Training/Lead Poison training for Amany
-Updated Personnel Policies
-Monthly Operating Statement (LIC 401)
-LPA Schnell will request an amended fire safety inspection to add room 606.
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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