434415366-10-14-2019-07-CC-SYIP-BGXVVB-20191014164604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415366
Report Date: 10/14/2019
Date Signed: 10/14/2019 04:46:08 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:	KCE CHAMPIONS LLC @ DEL BUONO ELEMENTARY		FACILITY NUMBER:	434415366
ADMINISTRATOR:	HELEN DE LA CRUZ		FACILITY TYPE:	840
ADDRESS:	9300 WREN AVENUE		TELEPHONE:	(408) 707-9381
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	56	CENSUS: 13	DATE:	10/14/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:27 PM
MET WITH:	Dawn Martin		TIME COMPLETED:	04:50 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	Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced annual random inspection. LPA met with Site Supervisor Dawn Martin and explained the reason for the inspection. Upon arrival of inspection, there were no school-age children and 2 staff. The hours of operation are Monday, Tuesday, Thursday, and Friday from 1:45PM-6PM and Wednesday from 1:00PM to 6PM. Facility is located on the Antonio Del Buono Elementary School campus. There were 13 children and 2 staff. The teacher child ratio was observed to be in compliance during today's inspection. LPA reviewed the sign in/out sheet. License, Emergency Disaster Plan, and Notification of Parent's Rights were observed to be posted. LPA toured in the inside and outside of the facility with Site Supervisor. Facility was observed to be clean and sanitary. Disinfectants, cleaning supplies, and other items that are dangerous to children were stored inaccessible to children in care. Furniture and equipment, such as tables and chairs, were age-age appropriate and in good condition. LPA observed there is sufficient amount of age appropriate toys for children in care. The floors were free of tripping hazard. Restroom for children's use were in functioning condition. Storage container for waste have tight-fitted lids. There is fully charged fire extinguisher, functioning smoke detector, and carbon monoxide detector. Site Supervisor stated that there are no weapons, such as firearms, stored on the premise. The outdoor area is fenced. Facility only uses the playground on campus. The playground equipment outside were maintained in safe condition, free of sharp, loose or pointed parts. Areas around play structures were cushioned with resilient materials to absorbs falls. Site Supervisor stated that they will sweep the playground before children play outside and even out the resilient material. Shaded rest areas are provided through building overhang. LPA did not observe any bodies of water. -----------------------continues on 809 dated 10/14/2019 page 2---------------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2019

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: KCE CHAMPIONS LLC @ DEL BUONO ELEMENTARY	FACILITY NUMBER: 434415366
	VISIT DATE: 10/14/2019

NARRATIVE

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--------------------continuation of 809 dated 10/14/2019 page 1------------------------------------

Facility does provide snacks to the children in care. Menu was observed to be posted. LPA observed kitchen used to store and prepare snacks. Drinking water is provided through water fountains.

8 children's files were reviewed during today's inspection. The records reviewed include but not limited to parent's rights and admission agreement.

2 staff files were reviewed during today's inspection. The records reviewed include but not limited to education credits, Mandated Reporter Training, and immunization records for pertussis and measles. There is currently at least one staff with valid CPR/1st aid, which expires on 02/2021.

Staff present during the inspection have cleared criminal record and child abuse index clearance or exemption. LPA also reminded Director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Site Supervisor stated that she currently does not have any children in care who requires Incidental Medical Services (IMS) services. 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.

Site Supervisor is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online Licensing Forms, Adoption of new Laws, etc.

No deficiencies were cited as a result of today's inspection. An exit interview was conducted, where this report was discussed and provided to Site Supervisor. A NOTICE OF SITE VISIT WAS ISSUE AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2019

LIC809 (FAS) - (06/04)

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