434414261-9-13-2019-07-CC-MMAR-BFQ2PX-20190904173503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414261
Report Date: 09/04/2019
Date Signed: 09/13/2019 03:41:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	KU CHAMPIONS @ CEDAR GROVE ELEMENTARY		FACILITY NUMBER:	434414261
ADMINISTRATOR:	CATHY CASTANEDA		FACILITY TYPE:	840
ADDRESS:	2702 SUGARPLUM DRIVE		TELEPHONE:	(408) 707-9381
CITY:	SANJOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	56	CENSUS: 33	DATE:	09/04/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Jacob Corona/Kaela Huettl		TIME COMPLETED:	05:45 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	* This is an amended report.* On 09/04/19 Licensing Program Analysts (LPAs), Monica Mathur and Nancy Rodriguez conducted an unannounced annual/random inspection at Ku Champions @ Cedar Grove Elementary. LPA met with Teachers, Jacob Corona and Kaela Huettl. Jacob stated that Director, Cathy Castaneda had left for the day. LPAs spoke with Ilse Richter, Site Director @ Ledesma and Tamara Payne Alex, Area Manager. Tamara authorized Teacher Kaela to sign the report on Director's behalf. LPA notes that the Facility is located on the campus of Cedar Grove Elementary School in the Multipurpose Room. A review of staff records indicates that Teacher, Jacob Corona has criminal record and child abuse clearances associated to another Champions facility, but is not associated to this facility. Jacob has been working at this facility for two years. A Type B citation was issued for Criminal Record Clearance and a Civil Penalty of $100 was assessed. Present in the Multipurpose Room were 2 teachers (fully qualified) with 33 school age children. Facility is not in compliance with required Teacher Child Ratio regulations. Type A Citation issued on page 809-D. LPA toured the Facility both inside and outside during today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus, and Activity Schedule.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2019

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KU CHAMPIONS @ CEDAR GROVE ELEMENTARY	FACILITY NUMBER: 434414261
	VISIT DATE: 09/04/2019

NARRATIVE

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In the areas that were evaluated, regulatory violations were observed. Therefore, citations were issued. Exit Interview was conducted, where this report, the citations, plan of corrections, civil penalty and appeal rights were reviewed and discussed over the phone with Area Manager, Tamara, who authorized teacher Kaela to sign the report.

Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to the parent of children enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2019

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KU CHAMPIONS @ CEDAR GROVE ELEMENTARY	FACILITY NUMBER: 434414261
	VISIT DATE: 09/04/2019

NARRATIVE

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LPA reviewed ten children's and 2 staff files. Each child's file reviewed contains the Information and Emergency Information form (LIC 700). There is at least one staff with current CPR and First Aid certifications on file. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips).

The Facility is aware of the required sign in and sign out procedures for school age children who arrive and leave on their own. Director states that all children are picked up by their respective parent(s)/guardian(s) and no child is allowed to go home on his/her own.
LPA observed that room was clean and safe for all children and staff. Director states that the Facility has a third-party cleaning service that cleans the Facility Monday through Friday in the evenings. Drinking water is readily available for the children in room and in the outdoor playground area via drinking fountains and pitchers/disposable cups. LPA observed solid waste containers with tight-fitting lids in each room. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff bathroom stall not utilized by the children which an isolated sick child can use if needed. Director states that there are no weapons or firearms on the premises.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored in locked cabinets inaccessible to children. Any poisons are stored in the locked storage cabinet.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. There is sufficient resilient materials (rubber padding) in the outdoor playground area. LPA did not observe any bodies of water.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2019

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KU CHAMPIONS @ CEDAR GROVE ELEMENTARY	FACILITY NUMBER: 434414261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/05/2019 Section Cited	1 2 3 4 5 6 7	101516.5(b) Teacher Child Ratio: There shall be a staffing ratio of one teacher and one aide present to every 28 children in attendance. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Per LPA's observations, there were 2 staff present with 33 children. Facility is not in compliance with required teacher child ratios today. This poses an immediate risk to the children in care.	8 9 10 11 12 13 14	Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to the parent of children enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.
Type B 09/05/2019 Section Cited	1 2 3 4 5 6 7	This is an amendment to the report originally issued on 09/04/19. Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance [...]. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Per LPA's review of staff records, an employee Jacob Corona has been employed in this facility for 2 years, has criminal record and child abuse clearances associated to another Champions facility, but is not associated to this facility. This poses an potential risk to the children.	8 9 10 11 12 13 14	A civil penalty of $100 has been assessed.

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: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2019

LIC809 (FAS) - (06/04)

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