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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415372
Report Date: 08/12/2022
Date Signed: 09/27/2022 10:24:10 AM

Document Has Been Signed on 09/27/2022 10:24 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
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: 64TOTAL ENROLLED CHILDREN: 64CENSUS: 25DATE:
08/12/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Tamara Payne-AlexTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Samantha Yip conducted an announced Case Management-Licensee Initiated inspection. LPA met with Tamara Payne-Alex and explained the reason for the inspection. The purpose of this inspection is the facility is requesting to use the Library on campus. Facility is located on Rod Kelley Elementary campus. A updated fire clearance was granted on 08/10/2022.

Since this School-Age Center will be operating on a functioning school site, the Center is exempt from requirement of square-footage for indoor and outdoor activity space, and toilet, fencing, and isolation space requirements for child day care centers, pursuant to Health and Safety Code Section 1596.806.

LPA inspected the library. All disinfectant, cleaning supplies, and other items that are dangerous to children were inaccessible to children. Facility will be brining toys and equipment for children. There is fully charged fire extinguisher and smoke detector. There is carbon monoxide detector in the portables. Tamara stated that she will bring carbon monoxide detector to the Library. Tamara stated that there are no weapons, such as firearms, stored on the premise. There are bathrooms for children who provide for individual privacy and is separated.

Facility will only be providing non-perishable snacks . Drinking water is provided through water fountains. There is a menu that was posted. Tamara will be bring tight-fitted trash can to the library.

--------------------------continuation of 809 dated 08/12/2022 page 2-------------------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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 @ ROD KELLEY ELEMENTARY
FACILITY NUMBER: 434415372
VISIT DATE: 08/12/2022
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----------------------continuation of 809 dated 08/12/2022 page 1------------------------

Facility will be using the playground and blacktop area. Areas around play structure have resilient materials. Shaded rest area is provided through trees. There were no bodies of water observed during today's inspection.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A 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)/ (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
Facility does not plan on transporting children.

All adults present have cleared fingerprints. Facility representatives were reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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.

Facility will submit the following:
- proof of carbon monoxide detector
- area for required postings
- tight-fitted trash can

No deficiencies were cited as a result of this inspection. Exit interview conducted and report was reviewed with the facility representatives Tamara Payne-Alex. Tamara was advised that an updated license to include the Library will be issued and mailed. A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC809 (FAS) - (06/04)
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