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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415372
Report Date: 07/26/2022
Date Signed: 07/27/2022 04:18:40 PM


Document Has Been Signed on 07/27/2022 04:18 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:KCE CHAMPIONS LLC @ ROD KELLEY ELEMENTARYFACILITY NUMBER:
434415372
ADMINISTRATOR:HELEN DE LA CRUZFACILITY TYPE:
840
ADDRESS:8755 KERN AVENUETELEPHONE:
(408) 707-9381
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:64CENSUS: 37DATE:
07/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Gloria CastroTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Other inspection. LPA met with Site Director Gloria Castro and explained the reason for the inspection.

During today's inspection, S-1 was present at the facility. S-1 is not associated to facility. Facility has an LIC 9182 dated 05/17/2019 on file. Director stated that she faxed the form to Care Provider Management Bureau (CPMB). She does not have any confirmation that it was received. LPA obtained a copy of the email the Director sent to CPMB regarding additional paperwork for S-1. Director stated that she did not receive an confirmation from CPMB. S-1 was associated to the KCE Champions LLC @ Del Buono Elementary #434415366. S-1 was separated from facility on 06/20/2022. S-1 is not associated to any other KCE Champion locations. LPA discussed with Site Director about keeping documentation that paperwork was received and to check that any transfer request were transferred.

Site Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

----------------------------continues on 809 dated 07/26/2022 page 2-------------------------------
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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 3


Document Has Been Signed on 07/27/2022 04:18 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: KCE CHAMPIONS LLC @ ROD KELLEY ELEMENTARY
FACILITY NUMBER: 434415372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2022
Section Cited

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 101170(f) or
This requirement is not met as evident by:
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Based on record review, S-1's fingerprints were not transferred to facility number, which poses an immediate risk to the health and safety to the children in care.
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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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


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 @ ROD KELLEY ELEMENTARY
FACILITY NUMBER: 434415372
VISIT DATE: 07/26/2022
NARRATIVE
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----------------------continuation of 809 dated 07/26/2022 page 1--------------------------------

LPA Samantha Yip informed Site Director Gloria Castro that this report dated 07/26/2022 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Site Director to provide a copy of this licensing report dated 07/26/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.


As a result of this inspection, a Type A citation was issued and civil penalty of $500 was assessed for caregiver background check. Exit interview conducted and report was reviewed with the site director, Gloria Castro. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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