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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414261
Report Date: 11/07/2024
Date Signed: 11/08/2024 11:23:55 AM

Document Has Been Signed on 11/08/2024 11:23 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 - CEDAR GROVEFACILITY NUMBER:
434414261
ADMINISTRATOR/
DIRECTOR:
MELIZA VIVEROSFACILITY TYPE:
840
ADDRESS:2702 SUGARPLUM DRIVETELEPHONE:
(408) 205-5383
CITY:SAN JOSESTATE: CAZIP CODE:
95148
CAPACITY: 56TOTAL ENROLLED CHILDREN: 55CENSUS: 42DATE:
11/07/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:52 PM
MET WITH:Meliza ViverosTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 11/07/2024 at 12:52pm, Licensing Program Analyst (LPA), Farida Raja, met with Site Director, Meliza Viveros, for an unannounced annual/random inspection in the School Age Program. The facility provides before and after school care to children from kindergarten through 6th grade in the multipurpose room located on the Cedar Grove Elementary School campus. LPA observed the required posted materials including menus and daily activity schedule. Days and hours of operation are Monday through Friday, 7AM to-8:30 AM and 2:35 PM - 6:00 PM and 1:15 PM-6:00 PM on Thursdays.

Children arrived at 1PM after dismissal from school and at 1:24pm LPA observed 41 children and 2 staff. Facility is not in compliance with teacher-child ratio requirement during today's inspection. Director stated that they are short staffed and working to hire new staff.

LPA toured the indoor and outdoor areas of the School Age Program. Classroom, children's restrooms and outdoor area were inspected. Children were engaged in homework and other activities under supervision of staff. LPA observed disinfectants, cleaning solutions and medications were stored in closet inaccessible to children. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. LPA observed solid waste container with a broken cover. LPA reminded Director that all containers used for storage of solid wastes, including moveable bins, shall have a tight fitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof. Director states that there are no weapons on the premises. There is a working telephone at the facility.

LPA observed a 2A10BC fire extinguisher and facility has built in smoke detector/ fire system. Last fire drill was conducted on 08/23/2024 which is within the 6-month requirement.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 - CEDAR GROVE
FACILITY NUMBER: 434414261
VISIT DATE: 11/07/2024
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Foods and beverages were stored safely. Food storage and preparation areas were observed to be sanitary. The facility provides breakfast and afternoon snacks. Monthly menu was observed posted outside the classroom.

Drinking water is readily available for the children in the room and in the outdoor playground area via individual water bottles and drinking water fountains. Water lead testing was completed by the facility and no Action Level Exceedances were reported. Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. LPA provided Director with the Water Lead Report from the California State Water Resources Control Board during today's inspection.

Director stated that children use the elementary school playground. Younger children use one play area and the older children use another play area. Outdoor playground and play equipment was inspected and observed to be in good condition, age-appropriate, and has sufficient resilient materials (rubber tiles) to absorb falls. Shade is provided by canopies on the play structure and trees. There were no bodies of water observed.

Children sign in and out procedures and logs were reviewed. Facility roster was reviewed and a copy was obtained. LPA reviewed ten (10) children's files. All children's files were complete with all required documentation.

LPA reviewed one (1) staff file during today's inspection. At least one staff member on site has a current CPR and First Aid certification on file. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). Staff has immunization's against pertussis, measles and statement declining influenza. LPA also observed the current Mandated Reporter Training on file for staff. LPA obtained an updated Personnel Report (LIC 500) and Emergency Disaster Plan (LIC 610) during today's inspection.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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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 - CEDAR GROVE
FACILITY NUMBER: 434414261
VISIT DATE: 11/07/2024
NARRATIVE
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Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Director stated that facility does handle medications. Upon review of medication, LPA observed Child (C1)'s medication has expired but has not been returned to authorized representative by the facility. Facility has already obtained new medication for the child. LPA reminded Director to check expiration dates on medications and return expired medication to authorized representatives.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. Director does not have children in care who require Incidental Medical Services (IMS). When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. All medications at the facility were observed to be stored in high cabinets out of reach of children. Isolation of sick child was discussed, and Director explained that sick children will be isolated near the Director's desk away from other children and isolation equipment will be provided. A staff restroom which is off limits to other children is used if necessary. Child is always under visual supervision while in care of the facility.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility does not provide transportation to children, but Director understands that children cannot be left alone, unattended in parked vehicles.

Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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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 - CEDAR GROVE
FACILITY NUMBER: 434414261
VISIT DATE: 11/07/2024
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One Type A deficiency and two technical violations were cited today. Appeal rights and LIC 9224 were printed and provided to Director. Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to any newly enrolled parents/guardians enrolled over the next 12 months from the date of this report. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file to confirm receipt of licensing report. LPA reminded Licensee that failure to correct deficiencies by Plan of Correction Due Date may result in civil penalties.

Exit interview was conducted and report was reviewed with Director, Meliza Viveros.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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Document Has Been Signed on 11/08/2024 11:23 AM - It Cannot Be Edited


Created By: Farida Raja On 11/07/2024 at 03:33 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 - CEDAR GROVE

FACILITY NUMBER: 434414261

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101516.5(b)(1)
Teacher-Child Ratio
(b) There shall be a staffing ratio of one teacher and one aide present to every 28 children in attendance. (1) A teacher shall supervise no more than 14 children or with an aide a maximum of 28 children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed 41 children and 2 staff during today's inspection. Director stated that they are short staffed and working to hire new staff.
POC Due Date: 11/08/2024
Plan of Correction
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Director to submit a written plan of correction to LPA by 11/08/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


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