434414261-9-28-2023-07-CC-FRAA-CW4VSS-20230928164200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414261
Report Date: 09/27/2023
Date Signed: 09/28/2023 04:42:08 PM

Document Has Been Signed on 09/28/2023 04:42 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	KCE CHAMPIONS LLC - CEDAR GROVE		FACILITY NUMBER:	434414261
ADMINISTRATOR:	CATHY CASTANEDA		FACILITY TYPE:	840
ADDRESS:	2702 SUGARPLUM DRIVE		TELEPHONE:	(408) 624-0533
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	56	CENSUS: 30	DATE:	09/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Meliza Viveros		TIME COMPLETED:	06:00 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	On 09/27/2023 at 1:40pm, Licensing Program Analyst (LPA), Farida Raja, met with Site Director, Meliza Viveros, for an unannounced annual inspection in the School Age Program. The facility provides before and after school care to children from kindergarten through 6th grade in the multipurpose rooms located on the Cedar Grove Elementary School campus. LPA observed the required posted materials including menus and daily activity schedule. Days and hours of operation are Monday through Friday, 7am-8:30am and 2:00pm - 6:00pm. Children arrived at 2:25pm after dismissal from school and LPA observed 30 children and 3 staff including director during today's inspection. LPAs toured the indoor and outdoor areas of the School Age Program during today's inspection. The classroom, children's restrooms and food storage area were inspected. Children were engaged in homework and other activities under supervision by staff. LPA observed disinfectants and cleaning solutions were stored in closet inaccessible to children. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Restrooms for children were observed to be in safe, sanitary, and in functioning condition. Children's bathrooms have working cold water faucets and no hot water. Drinking water is readily available for the children in each room and in the outdoor playground area via individual water bottles and disposable water bottles. LPA observed solid waste container with tight-fitting lid in the room. Director states that there are no weapons on the premises. There is a working telephone at the facility (408-205-5383) LPA observed a 2A10BC fire extinguisher and facility has built in smoke detector/ fire system. Director stated that they have not conducted a fire drill. LPA informed director that fire/disaster drills need to be conducted and documented every 6 months at childcare centers. Continued on Page 2

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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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Document Has Been Signed on 09/28/2023 04:42 PM - 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KCE CHAMPIONS LLC - CEDAR GROVE	FACILITY NUMBER: 434414261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Director stated that water lead testing has not been completed for this facility.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Director will conduct water lead testing and submit report to LPA by Plan of correction date of 10/11/2023.

Type B

Section Cited

CCR

101174(d)(2)

Disaster and Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Director will conduct a fire/disater drill and submit log to LPA by plan of correction date of 10/11/2023.

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: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 04:42 PM - 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KCE CHAMPIONS LLC - CEDAR GROVE	FACILITY NUMBER: 434414261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above for staff S2, S3 and S4 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	LPA will submit proof of completed Health Screening for all staff to LPA by Plan of Correction date of 10/11/2023.

Type B

Section Cited

CCR

101216.1(g)

Teacher Qualifications and Duties

(g) A photocopy of the teacher's Child Development Permit as specified in (c)(3) above, or a photocopy of the teacher's transcript(s) documenting successful completion of required course work, shall be maintained at the center. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited for staff S1 and S2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Director will submit transcripts for Staff S1 and S2 to LPA by Plan of Correction date of 10/11/2023.

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: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 04:42 PM - 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KCE CHAMPIONS LLC - CEDAR GROVE	FACILITY NUMBER: 434414261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101212(b)

(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as the Department was not notified of changes in Site Director, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Director will submit new director paperwork to LPA by plan of correction date of 10/11/2023.

Type B

Section Cited

HSC

1596.841

Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the director did not comply with the section cited above as the facility roster has not been updated, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Director will submit an updated roster to LPA by plan of correction date of 10/11/2023.

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: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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

FACILITY NAME: KCE CHAMPIONS LLC - CEDAR GROVE	FACILITY NUMBER: 434414261
	VISIT DATE: 09/27/2023

NARRATIVE

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Foods and beverages were stored safely. Food storage and preparation areas were observed to be sanitary. The facility provides morning and afternoon snacks and children are allowed to bring their own snacks. The menu is in writing and posted at least one month in advance, accessible to authorized representatives.

Facility did not complete water lead testing prior to deadline. 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. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. LPA referred director to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Director stated that children use the elementary school playground. Transitional kindergarten and kindergarten children use one play area and the older children use another play area. Outdoor playground and play equipment was inspected and observed to be in good condition, age-appropriate, and has sufficient resilient materials (rubber mats) to absorb falls. Shade is provided by canopies on the play structure and trees. There were no bodies of water observed.

Children sign in and out procedures and logs were reviewed. Director did not have an updated roster during today's inspection. LPa reviewed eleven (11) children's files. All children's files were complete with all required documentation.

LPA reviewed four (4) staff files during today's inspection. Staff S1 and S2 did not have required transcripts and verification of experience on file. At least one staff member on site has a current CPR and First Aid certification 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). All staff have the required Immunization's against pertussis, measles and influenza/ influenza declination letter. Staff, S2, S3 and S4 do not have the required Health Screening Record (LIC 503) on file. LPA observed the required Mandated Reporter Training on file for all staff.

Continued on Page 3

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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

FACILITY NAME: KCE CHAMPIONS LLC - CEDAR GROVE	FACILITY NUMBER: 434414261
	VISIT DATE: 09/27/2023

NARRATIVE

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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.

Director stated that facility does not handle medications and currently has no children in care who require Incidental Medical Services (IMS). Isolation of sick child was discussed, and Director stated that sick children will be isolated near the director desk and isolation equipment will be provided. A staff restroom which is off limits to other children is used if necessary. Child is always under visual supervision while in care of the facility. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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/.

Facility does not provide transportation to children, but Director understands that children cannot be left alone, unattended in parked vehicles. 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.

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

Six (6) Type B deficiencies were cited today on the attached LIC 809D pages. Appeal rights were printed and provided to Director. LPA reminded director that failure to correct deficiencies by Plan of Correction Due Date may result in penalties of $100 per day per violation.Exit interview was conducted with Director, Meliza Viveros.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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