434415375-9-27-2022-07-CC-SYIP-CJNNF7-20220927102504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415375
Report Date: 08/12/2022
Date Signed: 09/27/2022 10:25:07 AM

Document Has Been Signed on 09/27/2022 10:25 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 ELEMENTARY		FACILITY NUMBER:	434415375
ADMINISTRATOR:	DE LA CRUZ, HELEN		FACILITY TYPE:	840
ADDRESS:	9225 CALLE DEL REY		TELEPHONE:	(408) 707-9381
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	56	CENSUS: 0	DATE:	08/12/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Tamara Payne-Alex		TIME COMPLETED:	10:40 AM

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	Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced 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 Multi-Purpose room on campus. Facility is located on the Luigi Aprea Elementary campus. A 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. Facility will be using a board to post required postings, such as license, daily activity schedule, personal's rights, parent's rights, and menu. Tamara stated that she will send a picture of area to post required posting to license. LPA inspected the inside and outside of the facility. Disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible to children. There are bathrooms for the children adjacent to the Multi-purpose Room, which allows for individual privacy. LPA discussed with Tamara that about designating the bathroom so the girls and boy are separated. Facility will also have access to the bathroom adjacent to the blacktop area; however, will be used by the school district run program. LPA discussed with Tamara that children from the programs cannot commingle and would need to submit a waiver request. Facility will be bringing supplies and toys for children. There is fully charged fire extinguisher and smoke detector. There is a carbon monoxide detector in the portable unit. Tamara stated that they will move carbon monoxide detector to the room and send proof to Licensing. Tamara stated that there are no weapons, such as firearms, stored on the premise. --------------------------------continues on 809 dated 08/12/2022 page 2-------------------------

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
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 @ LUIGI APREA ELEMENTARY	FACILITY NUMBER: 434415375
	VISIT DATE: 08/12/2022

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----------------------continuation of 809 dated 08/12/2022 page 1-------------------------------

The outdoor area is fenced. Facility will be using the blacktop area and the kindergarten yard. Area around play structure has resilient material. LPA discussed with Tamara that the play structure is for ages 5-12 years old. Shaded rest area is provided through building overhang and trees. There were no bodies of water observed during today's inspection.

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

Facility will not be transporting children at this time.

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.

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
- trash in the basketball court is cleared

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 Multi-purpose Room 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.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
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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