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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416446
Report Date: 12/07/2021
Date Signed: 01/27/2022 10:06:24 AM

Document Has Been Signed on 01/27/2022 10:06 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 @ STOCKLMEIR ELEMENTARYFACILITY NUMBER:
434416446
ADMINISTRATOR:ANGELA ZARETZKAFACILITY TYPE:
840
ADDRESS:592 DUNHOLME WAYTELEPHONE:
(408) 665-9444
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 90TOTAL ENROLLED CHILDREN: 0CENSUS: 13DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Angela Zaretzka TIME COMPLETED:
07:30 PM
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Licensing Program Analysts (LPAs) Aman Sharma and Samantha Yip conducted an unannounced Required 1 Year inspection. LPA met with Director Angela Zaretzka Nelson and explained the reason for the inspection. Present during the inspection were 13 children and Director. Facility was within ratio during today's inspection. Facility is located on the Stockmeir Elementary School campus in Room 31, 32, and 33. Facility is currently only using Room 32, the blacktop, playground, and girls and boys restroom on campus.

There is a board to post required postings, such as license. LPA discussed with Director about required postings, such as Notification of Parent's Rights, Personal Rights, and Earthquake Preparedness Checklist. Director stated that she will take a picture of board with updated postings to Licensing. There is working phone at the facility. LPAs reviewed sign in/sign out sheet.

LPA toured the inside and outside of the facility. There is sufficient amount of toys for children in care. All furniture and equipment were observed to be in good condition. Disinfectants, cleaning supplies, and other items that could pose a risk to children were inaccessible to children. LPAs observed that there were three boxes with 5 gallon jugs under the children's sink, but was unable to identify what the content was inside. LPAs discussed with Director about putting a lock on the cabinets. There is fully charged fire extinguisher, smoke detector, and carbon monoxide detector.

The outside area was fenced. Play structure was observed to be in good condition and there is resilient material to absorb falls. Shaded rest area is provided through trees and building overhang. There were no bodies of water observed during today's inspection.

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NAME OF LICENSING PROGRAM MANAGER: Sandy Knight
NAME OF LICENSING PROGRAM ANALYST: Aman Sharma
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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 @ STOCKLMEIR ELEMENTARY
FACILITY NUMBER: 434416446
VISIT DATE: 12/07/2021
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-----------------CONTINUATION OF 809 DATED 12/07/2021 PAGE 1------------------------

Facility only provides snacks to children. Menu was observed to be posted. All snacks are prepared by the school district. There is a fridge to store snacks. Drinking water is provided through water fountains and water bottle refill on campus.

The facility provides Incidental Medical Services- IMS. Director stated that the medication is in the office. They do have access to the medication in the office, but it closes around 4:30PM to 5PM. LPA discussed with Director about obtaining an epi-pen for the room in case of an emergency. Director stated that she will send proof to Licensing.

9 children's files were reviewed during today's inspection. The records reviewed include but not limited to Emergency Card, admission agreement, and parent's rights. LPA observed that four (4) children did not have parent's rights in file. Director stated that she will have parents fill it out and send a copy to Licensing. LPAs observed that 8 children did not have admission agreement on file. Director stated that it is on the parent portal and does not have access to it. Director stated that she will send a copy to Licensing.

One staff file was reviewed during today's inspection. The records reviewed included but were not limited to transcript and Mandated Reporter Training. Director has an exception on file to be director although she was missing 1 semester unit. Exception required facility to submit transcript by 10/31/2020. No transcript was submitted to Licensing. Director completed Admin/supervision course and the grade on file, but did not have a transcript, which shows the number of units completed. Director attempted to call the school and left a email with school to obtain transcript. Director stated that she will submit transcript to Licensing as soon as she obtains a copy. Director completed only the General Training for the Mandated Reporter Training. LPA discussed with Director that she needs to complete the Child Care Provider training. Director stated she will complete it and submit a copy to Licensing. Director has a valid CPR/1st Aid, which expires on 03/2023.

----------------------CONTINUES ON 809 DATED 12/07/2021 PAGE 3----------------------
NAME OF LICENSING PROGRAM MANAGER: Sandy Knight
NAME OF LICENSING PROGRAM ANALYST: Aman Sharma
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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 @ STOCKLMEIR ELEMENTARY
FACILITY NUMBER: 434416446
VISIT DATE: 12/07/2021
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-------------------CONTINUATION OF 809 DATED 12/07/2021 PAGE 2-------------------------

All staff present have cleared criminal record clearance. 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. Director stated that she is going to have volunteer get fingerprinted, but comes in to help with paperwork.

Director stated that she will submit the following:

- Transcript for admin/supervision

- Child Care Provider Mandated Reporter training certificate

- Notification of Parents' Rights

- Admission Agreement

As a result of this inspection, one Type B citation and technical violations have been cited. Exit interview was conducted and report was discussed with Director Angela Nelson. A Notice of Site Visit has been issued and must be posted for 30 days.

Due to inspection tool still processing, LPAs were unable to provide technical violations to Director. LPA advised Director that LPA will return to deliver technical violations.

NAME OF LICENSING PROGRAM MANAGER: Sandy Knight
NAME OF LICENSING PROGRAM ANALYST: Aman Sharma
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2022 10:06 AM - It Cannot Be Edited


Created By: Aman Sharma On 12/07/2021 at 06:06 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 @ STOCKLMEIR ELEMENTARY
FACILITY NUMBER: 434416446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101218.1(e)(1)
At the time of acceptance of each child into care and for all children in care on August 7, 2002, the licensee shall give each parent or authorized representative a copy of the Notification of Parents' Rights (LIC 995 [8/02]) and the LIC 995E, Caregiver Background Check Process form.

(1) The licensee shall request the child’s parent or authorized representative to sign and date the acknowledgement-of-receipt statement at the bottom of the LIC 995 (8/02). The bottom portion of this form must be kept in the child's file as proof that the parent or authorized representative has been notified of his or her rights by the child care center and received a copy of the LIC 995E, Caregiver Background Check Process form.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above. LPA observed that 4 children did not have form in file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2021
Plan of Correction
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Director stated that she will have parents fill out form and send a copy to Licensing.

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:Sandy Knight
LICENSING EVALUATOR NAME:Aman Sharma
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2021


LIC809 (FAS) - (06/04)
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