434415371-10-3-2019-07-CC-MMAR-BGLUM6-20191003154148

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415371
Report Date: 10/03/2019
Date Signed: 10/03/2019 03:41:53 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 @ LEDESMA ELEMENTARY		FACILITY NUMBER:	434415371
ADMINISTRATOR:	HELEN DE LA CRUZ		FACILITY TYPE:	850
ADDRESS:	1001 SCHOOLHOUSE ROAD		TELEPHONE:	(408) 707-9381
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95138
CAPACITY:	55	CENSUS: 26	DATE:	10/03/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Ilse Richter		TIME COMPLETED:	04:00 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 10/03/19 Licensing Program Analyst (LPA), Monica Mathur conducted an unannounced annual/random inspection at KCE Champions LLC @ Ledesma Elementary - School Age Program. LPA met with Director, Ilse Richter had explained the purpose of today's inspection. LPA notes that the facility is located on the campus of Ledesma Elementary School in the portable room. Present in the room were Director and 2 teachers (fully qualified) with 26 school age children. Facility is in compliance with required Teacher Child Ratio regulations. On normal school days, this program operates in two shifts: M-F Mornings 6:30 AM - 8:30 AM after which children leave to attend school at Ledesma Elementary. M-F Afternoons 2:00 PM - 6:00 PM. Kindergarten children are picked up by staff and escorted back to the program, while older ones walk down to the portable. Ledesma Elementary is closed Sept 30 - Oct 4, observing Fall Week. School Age program is operating full days, M-F from 6:30 AM - 6:00 PM during this week. 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. LPA reviewed ten children's and Director 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). Continued on next page. Report dated 10/03/19.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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 @ LEDESMA ELEMENTARY	FACILITY NUMBER: 434415371
	VISIT DATE: 10/03/2019

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
26
27
28
29
30
31
32

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. 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.

In the areas that were evaluated, no regulatory violations were observed. Exit Interview was conducted, where this report was reviewed and discussed with Director.

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

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2019

LIC809 (FAS) - (06/04)

Page: 2 of 2