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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416446
Report Date: 01/27/2022
Date Signed: 01/27/2022 10:14:33 AM

Document Has Been Signed on 01/27/2022 10:14 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: 90CENSUS: 0DATE:
01/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Angela NelsonTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPAs) Aman Sharma and Melvin Matos conducted an unannounced case management inspection and met with Angela Nelson (Zaretzka), director. Purpose of today's inspection: plan of correction for one Type B deficiency issued on December 7, 2021.

The director provided proof of correction to LPA Aman and LPAs also reviewed the four children's files during today's inspection. It is therefore concluded that the Type B deficiency issued on December 7, 2021 per Section 101218.1(e)(1) of Title 22 regulations is thus cleared.

LPAs also provided a copy of the Facility Evaluation Report dated December 7, 2021 to Angela prior to the conclusion of today's inspection.

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.
NAME OF LICENSING PROGRAM MANAGER: Diana Stephenson
NAME OF LICENSING PROGRAM ANALYST: Aman Sharma
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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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