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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415371
Report Date: 04/10/2023
Date Signed: 04/20/2023 09:40:23 AM


Document Has Been Signed on 04/20/2023 09:40 AM - 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 @ LEDESMA ELEMENTARYFACILITY NUMBER:
434415371
ADMINISTRATOR:HELEN DE LA CRUZFACILITY TYPE:
840
ADDRESS:1001 SCHOOLHOUSE ROADTELEPHONE:
(408) 624-0533
CITY:SAN JOSESTATE: CAZIP CODE:
95138
CAPACITY:55CENSUS: 15DATE:
04/10/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ilse RichterTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Farida Raja and Anna Morales, conducted an unannounced case management inspection to discuss the water lead testing which resulted in one action level exceedance at the facility. LPA met with Site Director, Ilse Richter, and explained the purpose for the inspection. LPA toured the facility and requested to identify Sample Site ‘F’ with reported Action Level Exceedance (value of 5.5 parts per billion or greater). The lead testing was completed by Clinical Lab of San Bernardino, Inc on December 10, 2022 indicated site "F" had an Action Level Exceedance (ALE) value of 16 ppb. LPA's observed that the bubbler with the ALE is located in one of the classrooms. LPAs requested that the facility submit plan of correction for site "F" to ensure that it is not used for food preparation or children's drinking water.

While LPAs were present Site Director covered the bubbler with a plastic bag, taped the nozzle and put up signage stating that it should not be used. Site Director stated that the children do not use this bubbler and refill water bottles from the bathroom sinks. LPAs observed that children have their own individually labeled water bottles.

The following documents were submitted to analysts during today's inspection:
1) Self-Certification (LIC9275) completed by Certified External Water Sampler
2) Sampling Checklist Form (LIC9276)
3) Facility Sketch (LIC999) labeled with locations of water outlets that were tested.
4) Water Lead Test Report

Type B deficiency was cited, exit interview conducted, and a copy of this report was given and reviewed with the Site Director, Ilse Richter. Appeal rights were reviewed and provided. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
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 04/20/2023 09:40 AM - 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 @ LEDESMA ELEMENTARY
FACILITY NUMBER: 434415371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited

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Lead Testing Written Directives (b)(1) a result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.

This requirement was not met as evidenced by:
After water lead testing was completed, the facility had one faucet (F) located in the indoor preschool classroom with an Action Level Exceedance of 16, which poses a potential risk to the health, safety, and personal rights of children in care.
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The Site Director covered and taped the ALE bubbler and posted signage to ensure it is not used. Site Director will also submit a written letter stating that bubbler "F" will remain out-of-use and will ensure that it is not used for food preparation or children's drinking water.
Director submitted letter of understanding while LPAs were at facility.

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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 KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
LIC809 (FAS) - (06/04)
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