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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404972
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:53:13 AM


Document Has Been Signed on 11/17/2022 11:53 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:KCE CHAMPIONS LLC @ SANTA RITA ELEMENTARYFACILITY NUMBER:
434404972
ADMINISTRATOR:NIKOLE MILLERFACILITY TYPE:
840
ADDRESS:700 LOS ALTOS AVENUETELEPHONE:
(650) 946-7791
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY:56CENSUS: 0DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Luis SanchezTIME COMPLETED:
01:00 PM
NARRATIVE
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On 11/17/2022 at 9:00am, Licensing Program Analyst (LPA) Christina Uribe conducted an Unannounced Annual Required Inspection. LPA met with Site Director, Luis Sanchez, & Area Manager, Stefani Gindi, also present at the time of the inspection were 0 staff & 0 children. The facility is within ratio & capacity compliance today. LPA provided facility representative the Entrance Checklist (LIC 125). The facility was toured to conduct a Health and Safety inspection. The facility currently operates am program 7:00am-8:30am & pm program 2:30pm-6:00pm, Monday, Tuesday, Wednesday, & Friday and 1:15pm-6:00pm on Thursdays in one classroom. .

Classrooms: The classroom was inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged 3A40BC fire extinguisher that is accessible throughout the facility. The center is equipped with a fully stocked first-aid kit and available in the classroom.

Food Service Areas: All center provided food items are properly labeled & stored separately from cleaning supplies. Food prep area is clean, adequately equipped, & free from hazardous materials. Snack menu is posted one week in advance, available for review, & dated. Solid waste bins are equipped with tight fitting lid.

Bathrooms: Facility has separate staff and child designated bathrooms. Toilets and faucets are in safe and sanitary operating condition. The children are able to reach the sinks and toilets and supplies are available.

Outdoor Play Area: There are no bodies of water, or free-standing water accessible to children. There are age appropriate toys and materials for the children. The playground outside is fenced and all equipment and surfaces are free from hazards.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KCE CHAMPIONS LLC @ SANTA RITA ELEMENTARY
FACILITY NUMBER: 434404972
VISIT DATE: 11/17/2022
NARRATIVE
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Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 5 children’s files and 3 staff files. LPA reviewed the personnel report and copy was obtained. Facility Roster was reviewed. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. Director’s CPR/First-Aid Certificate is current and expires on 10/18/24. The sign in and out forms were reviewed. Emergency Drills are recorded and performed at least every six months. Per facility representative, there are no firearms on the premises. All required documents are posted in a publicly accessible area.

Health-Related Services: This facility does provide Incidental Medical Services (IMS) however no children have the need to medication to be stored at the facility at this time. For IMS information see Evaluator Manual – Regulation Interpretations & Procedures for Child Care Centers sections 101173 & 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

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Director 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.

Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KCE CHAMPIONS LLC @ SANTA RITA ELEMENTARY
FACILITY NUMBER: 434404972
VISIT DATE: 11/17/2022
NARRATIVE
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Deficiencies cited during today's inspection: Please see attached deficiency and advisory note pages for more information.
  • Type B Violation: Some personnel records do not have proof of immunization for Measles (MMR) and/or Pertussis (Tdap) for staff members
  • Type B Violation: Some staff members have not obtained a certificate for Mandated Reporter training for Child Care Providers (AB 1207).
  • Type B Violation: Director does not have a certificate of completion for the ESMA 8-hour Preventative Health & Safety Training.
  • Type B Violation: Some personnel records do not have a signed Health Screening Report (LIC 503) form and/or TB clearance.
  • Type B Violation: One child's file is missing the Consent for Emergency Medical Treatment (LIC 627) form.
  • Type B Violation: Sign in and out forms are missing sections for staff to sign children in and out from school each day.
  • Technical Violation: Personnel records are incomplete and some forms not immediately available for review as they are kept at the facility's administrative site.

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 the director, Luis Sanchez and Area Manager, Stefani Gindi.

Page 3 of 3 ***End of Report***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/17/2022 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: KCE CHAMPIONS LLC @ SANTA RITA ELEMENTARY
FACILITY NUMBER: 434404972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as three staff members do not have proof of immunizations for Measles (MMR) and/or Pertussis (Tdap) for staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Proof of immunization for Measles (MMR) and Pertussis (Tdap) will be obtained for each staff member and a copy will be emailed to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 12/16/22.
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 record review, the licensee did not comply with the section cited above as three staff members have not obtained a certificate for Mandated Reporter training for Child Care Providers (AB 1207) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Each staff member will complete the required training on www.mandatedreporterca.com. A copy of each certificate will be emailed to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 12/16/22.

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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 11/17/2022 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: KCE CHAMPIONS LLC @ SANTA RITA ELEMENTARY
FACILITY NUMBER: 434404972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101215.1(m)
Child Care Center Director Qualifications and Duties
(m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the director has not completed the required ESMA 8-hour Preventative Health & Safety training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Director will immediately register for this course and complete the training. A copy of the certificate will be emailed to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 12/16/22.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two staff members do not have a Health Screening Report (LIC 503) form and one does not have proof a TB clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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The staff members will obtain a signed copy of the Health Screening Report (LIC 503) form from their physician which will include proof of TB clearance. A copy of these forms will be emailed to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 12/16/22.

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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 11/17/2022 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: KCE CHAMPIONS LLC @ SANTA RITA ELEMENTARY
FACILITY NUMBER: 434404972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one child did not have a signed Consent for Emergency Medfical Treatment (LIC 627) form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Director will have the parent or authorized reporesentative of the child fill out this form and place it in the child's file. A copy of this signed form will also be emailed to LPA Uribe at christina.uribe@dss.ca.gov
Type B
Section Cited
CCR
101529.1(b)
Sign In and Sign Out
(b) Center staff shall sign in a school-age child who arrives at the center on his/her own.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the facility's sign in and out forms did not have a section for staff to sign children in and out from school which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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Director will ensure that a new form is used and that all parents will fill out the new form to reflect sign in and out times for the month of November 2022. A copy of these forms will be emailed to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 12/16/22.

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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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