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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416987
Report Date: 08/05/2021
Date Signed: 08/09/2021 02:04:33 PM

Document Has Been Signed on 08/09/2021 02:04 PM - 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 @ LAKESIDE ELEMENTARYFACILITY NUMBER:
434416987
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:19621 BLACK ROADTELEPHONE:
4083481610
CITY:LOS GATOSSTATE: CAZIP CODE:
95033
CAPACITY: 30TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/05/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Tamara Payne-AlexTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA), Stephanie Collins met Program director Tamara Payne-Alex. Applicant representative for KCE Champions LLC. is applying for a license to A School Age Program at the address listed above. The requested capacity is 30 School Age children ages 5 to 12 years old. During the inspection, Applicant's Representative Tamara Payne-Alex requested a commingling waiver for one hour in the A M’s and one hour in the P M’s between school age program and elementary school during A M drop-offs and P M pick-ups. Elementary). The A Fire Clearance was granted on 08/3/2021 by Santa Clara Fire Prevention LPA inspected the indoor and outdoor, on limit and off limit areas, as well as measured the space available for the children.

Indoor measurements are as follows:
School AGE Indoor active space:
Community Center Room and Music Room
= (Total sq. ft.) – (Total Encumbered Space) = (3,422.96 sq. ft.) + ( 864.90 sq. ft.) - (0. sq. ft.)
= 4,286.00 sq. ft.

Total Indoor Activity Space = (4,286.00 sq. ft..) divided by (35 sq. ft) = 122 / children


School Age outdoor activity Space = (57,725.98 sq. ft.) divided by (75 sq. ft. / child) = 769.00 School Age children
There are 7/105 toilet and 4/60 sinks for the School Age program children to use.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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 @ LAKESIDE ELEMENTARY
FACILITY NUMBER: 434416987
VISIT DATE: 08/05/2021
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LPA observed that the school age yard and field are enclosed by fencing. The School Age program and Elementary programs do not overlap so an alternating playground schedule is not required. The playground has wood-chips which serves as resilient materials under play structures, the areas around and under high climbing equipment, swings, slides and other similar equipment is cushioned with the same material field is grassy .

Shade is provided by trees and overhang. LPA did not observe any bodies of water during the visit. Site Director stated that facility will not provide transportation. LPA also observed age appropriate toys, furniture, and equipment. There are staff restroom in common area of school. The Director’s area can be used to isolate a sick child who becomes ill and isolation equipped is available. The School Age room has heating, lighting, and ventilation for the safety and comfort of children. First aid supplies were observed. Medications will be stored in a locked box in the classroom inaccessible to children.

Facility provides Morning and Afternoon snacks (shelf stable snacks) provided. Menu is posted. LPA observed trash cans with tight fitting covers for the disposal of solid waste.

Site Director Tamara Payne-Alex meets Director’s Educational Qualification requirement. There is at least one staff with current certification for preventive health practices training, which included current pediatric cardiopulmonary resuscitation and pediatric first aid certification. Director maintains documentation of immunity against Measles and Pertussis and required training. Site Director and Executive Director Background Check Clearance have been transferred to the School Age Program.

LPA reminded Site 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 up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person up to $3000.00 per person.

This facility plans to provide Incidental Medical Services – IMS and had submitted a Plan of Operation that includes IMS. 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.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
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 @ LAKESIDE ELEMENTARY
FACILITY NUMBER: 434416987
VISIT DATE: 08/05/2021
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Exit interview was conducted, where this report was reviewed with Site Director Tamara Payne-Alex and.

Applicant's Representatives were informed that the following pending items need to be submitted:
· LIC 404 Financial Verification.


Application will be forward to Management for final review and approval
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3