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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415375
Report Date: 01/25/2023
Date Signed: 01/26/2023 12:09:39 AM

Document Has Been Signed on 01/26/2023 12:09 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 @ LUIGI APREA ELEMENTARYFACILITY NUMBER:
434415375
ADMINISTRATOR:DE LA CRUZ, HELENFACILITY TYPE:
840
ADDRESS:9225 CALLE DEL REYTELEPHONE:
(408) 707-9381
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 56TOTAL ENROLLED CHILDREN: 56CENSUS: 37DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Kayla Fathali BlattTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Kayla Fathali Blatt, Site Director, and explained the reason for the inspection. Upon arrival, there were no children present. Facility is located on the Luigi Aprea Elementary School campus in the multi-purpose room and portables. Site Director stated that they currently do not use the portables and is still using the multi-purpose room.

There is area to post required postings, such as license, notification of parent's right. The hours of operation are Monday through Friday 6:30AM to 6PM. LPA reviewed the sign in/out sheet. LPA discussed with Director that children need to be signed in and out.

LPA toured the inside and outside of the facility. All disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible to children. There are toys for children. There is fully charged fire extinguisher and smoke detector. The carbon monoxide detector is located in the portables. The last fire/disaster drill was conducted on 01/17/2023.

Facility uses the blacktop and the playground adjacent to the portables. Area around the play structure has resilient material. LPA discussed with Site Director about ensuring that areas around the slide have enough resilient material. LPA also discussed with Site Director about the chain ladder on the play structure. LPA observed that the area that connects to the play structure was starting to have wear and tear. There was no bodies of water observed during today's inspection.

Facility does provide snacks to children. Snacks are prepared in the kitchen located in the portables. Menu was observed to be posted. Drinking water is provided through water cooler and cups.
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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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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 @ LUIGI APREA ELEMENTARY
FACILITY NUMBER: 434415375
VISIT DATE: 01/25/2023
NARRATIVE
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. C-1's medication was not in the original packaging. For IMS information see PIN 22-02-CCP. 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

Six (6) children's files were reviewed during today's inspection. The records reviewed include but not limited to admission agreement.

Three (3) staff files were reviewed during today inspection. The records reviewed include but not limited to education credit and Mandated Reporter training. There is at least one staff with a valid CPR/1st Aid, which expires on 10/2024. Based on record review, Site Director does not qualify to be a director. Facility will submit documents for a new site director by 02/24/2023.

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.

LPA observed at 224PM and 245PM that children from another program was in the multi-purpose room. LPA discussed with Site Director about ensuring that children from their program does not commingle with other programs.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/26/2023 12:09 AM - It Cannot Be Edited


Created By: Samantha Yip On 01/25/2023 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KCE CHAMPIONS LLC @ LUIGI APREA ELEMENTARY
FACILITY NUMBER: 434415375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101515(b)
School-Age Child Care Center Director Qualifications and Duties
(b) All school-age child care centers shall have a director.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of one persons, which poses a potential health, safety or personal rights risk to persons in care. Director does not qualify to be a director
POC Due Date: 02/24/2023
Plan of Correction
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By POC 02/24/2023, facility will submit required paperwork for a new site director to Licensing.
Type B
Section Cited
CCR
101226(e)(3)(A)
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in one out of one persons, which poses a potential health, safety or personal rights risk to persons in care. C-1's medication was not in the original packaging.
POC Due Date: 02/24/2023
Plan of Correction
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By POC 02/24/2023, facility will submit proof of packaging for medication for C-1.
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 Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/26/2023 12:09 AM - It Cannot Be Edited


Created By: Samantha Yip On 01/25/2023 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KCE CHAMPIONS LLC @ LUIGI APREA ELEMENTARY
FACILITY NUMBER: 434415375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101529.1(b)
Sign In and Sign Out
(b) Center staff shall sign in a school-age child who arrives at the center on his/her own.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Children were not signed in by center staff.
POC Due Date: 02/01/2023
Plan of Correction
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By POC 02/01/2023, faciltiy will submit written plan on how they will ensure that children are signed in at all time.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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 Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/26/2023 12:09 AM - It Cannot Be Edited


Created By: Samantha Yip On 01/25/2023 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KCE CHAMPIONS LLC @ LUIGI APREA ELEMENTARY
FACILITY NUMBER: 434415375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101538.39(b)
In combination programs, indoor activity space provided for school-age child care center children shall be physically separated from space provided for infant care and child care center children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that another program on campus was in the multi-purpose room.
POC Due Date: 01/26/2023
Plan of Correction
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By POC 01/26/2023, faciltiy will submit statement that they understand that their school-age program cannot share the same space as other program on campus.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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4
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 Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
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 @ LUIGI APREA ELEMENTARY
FACILITY NUMBER: 434415375
VISIT DATE: 01/25/2023
NARRATIVE
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------------------continuation of 809 dated 01/25/2023 page 2---------------------

As a result of this inspection, Type A and Type B citations were issued. Exit interview conducted and report was reviewed with the Site Director, Kayla Blatt. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

LPA Samantha Yip informed Site Director Kayla Blatt that this report dated 01/25/2023 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 01/25/2023 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.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6