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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414261
Report Date: 09/13/2019
Date Signed: 09/13/2019 03:47:16 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 ELEMENTARYFACILITY NUMBER:
434414261
ADMINISTRATOR:CATHY CASTANEDAFACILITY TYPE:
840
ADDRESS:2702 SUGARPLUM DRIVETELEPHONE:
(408) 707-9381
CITY:SANJOSESTATE: CAZIP CODE:
95148
CAPACITY:56CENSUS: 25DATE:
09/13/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cathy CastanedaTIME COMPLETED:
03:15 PM
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On 09/13/19 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Case Management inspection at Ku Champions @ Cedar Grove Elementary. LPA met with Director, Cathy Castaneda. The purpose of the inspection was to review the amended copies of previous report dated 09/04/19. LPA discussed the Amended Report LIC809 and 809-D pages dated 09/04/19 and corrections made to it. The amended report was given to the Director. There were 25 children and 3 staff present in the facility during today's inspection.

Exit interview was conducted, where this report was discussed with the Director.

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2019
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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