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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416682
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:14:23 AM

Document Has Been Signed on 12/15/2022 11:14 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KCE CHAMPIONS LLC @ BLUE HILLS ELEMENTARYFACILITY NUMBER:
434416682
ADMINISTRATOR:ISAAK RAMIREZFACILITY TYPE:
840
ADDRESS:12300 DE SANKA AVENUETELEPHONE:
(408) 665-9594
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY: 90TOTAL ENROLLED CHILDREN: 32CENSUS: 0DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Isaak RamirezTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA) Pietro Hernandez conducted an unannounced, Required 1 Year inspection, met with the School Age Program Director Isaak Ramirez, and explained the nature of today's inspection. KCE Champions at Blue Hills is located on the Blue Hills Elementary School grounds. There are currently no Facility Waivers.

LPA arrived prior to after school program so no children were present at the time of the arrival. LPA discussed and confirmed that Director understands capacity and ratio requirements and reviewed the sign in and sign out documentation and teachers schedules.

The after school facility occupies rooms 27 and 28 located at the back right hand side of the school..

The facility operates in compliance with teacher/ child ratios, children are not left unattended and are constantly under the direct visual supervision of a staff person. LPA discussed with Director the staff and children days includes interacting in various activities. Facility has a posted monthly snack menu. Current normal business hours Monday - Friday 2:00PM to 6:00 PM. (Tuesdays) and 1:00PM to 6:00PM respectively.

LPA completed a physical plant inspection touring the building inside and out. No bodies of water were found. Director stated that there are no weapons stored in the facility. Disinfectants, cleaning solutions, poisons, and other items that are dangerous to children were locked up and inaccessible. Furniture and equipment was in good condition, free of sharp, loose, or pointed parts. Fire drills are conducted on a monthly basis and the last entry was on 11/6/2022.

Continued on Page #2. Report dated 12/15/2022
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KCE CHAMPIONS LLC @ BLUE HILLS ELEMENTARY
FACILITY NUMBER: 434416682
VISIT DATE: 12/15/2022
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Facility has age appropriate furniture and equipment. All storage containers for solid waste had tight fitting covers and were in good repair. Facility was free of flies, other insects, and rodents. Facility has adequate indoor activity space for children that is physically separate from space used by the preschool child care center. Personal water bottles, dishes, and containers of food brought by the child's authorized representative are labeled with the child's name and current date. Facility has at least one functioning carbon monoxide detector, which are hard wired, two fire extinguishers (3A40BC) and fire pull stations that meets statutory requirements. Facility has adequate outdoor activity space and play equipment that is maintained in a safe condition and is free of hazards. The outdoor activity area is surrounded by appropriate fencing. The play structure and equipment outside were age appropriate in good condition. Areas around play structure were cushioned with resilient materials. Shaded rest areas are provided by canopy and trees and overhangs from the buildings. LPA did not observe any bodies of water.

All Staff were fingerprinted and associated to the facility. LPA reminded Director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day with a maximum of $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day with a maximum of $3000.00 per person. LPA also reviewed with Director the violations that would result in an immediate assessment of civil penalty in the amount of $500. Director is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.

There was at least one Teacher with current certification in Pediatric CPR and First Aid present at the facility during inspection. Director's CPR and First Aid 11/19/2023. Children's Roster was reviewed, and a copy obtained.

LPA Hernandez reviewed the files of 3 Staff and 10 children. All or the required documentation was available in the files.

Continued on Page #3 of Report dated 12/15/2022
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KCE CHAMPIONS LLC @ BLUE HILLS ELEMENTARY
FACILITY NUMBER: 434416682
VISIT DATE: 12/15/2022
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This facility does not provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

All staff have current Mandated Reporter Certificates on file. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed: www.mandatedreporterca.com.

TYPE A language: SHOULD THERE EVER BE AN ISSUANCE of Type A citations today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the Licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Isaak Ramirez, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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