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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414261
Report Date: 12/05/2024
Date Signed: 12/06/2024 08:42:58 AM

Document Has Been Signed on 12/06/2024 08:42 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: 42CENSUS: 40DATE:
12/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:Gloria CastroTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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On 12/05/2024 at 1:32pm, Licensing Program Analysts (LPAs), Farida Raja and Pedro Solorio- Gutierrez conducted an unannounced case management inspection. LPAs met with Substitute Director, Gloria Castro and explained the purpose of today's visit.

During today's inspection, LPAs observed 37 children and 2 staff. Facility had 40 children in attendance today with 2 staff. Facility is operating out of ratio and is not in compliance with ratio requirements. One Type A deficiency was cited. This is a repeat violation in a 12 month period as the same violation was cited on 11/07/2024. Substitute Director stated that staff called in sick and another staff is on the way. Third staff arrived at 2:30pm. LPA discussed teacher qualifications and ratio with Director and reminded Director that 1 teacher with an aide can supervise no more than 28 children and an additional teacher is required for over 28 children.

LPAs did not observe the Facility Inspection Report including the LIC 809, LIC 809C and LIC 809D pages with the Type A citation issued on 11/07/2024 posted at the facility. LPAs reminded substitute Director that this report needs to be posted for 30 days at the facility. LPAs did observe the Notice of Site Visit posted for the 11/07/2024 visit.

LPA's reviewed 11 children's files for the Acknowledgement of Receipt of Licensing Reports (LIC 9224) for the Type A cited on 11/07/2024. 5 out of 11 children's files reviewed did not have the signed LIC 9224 on file. LPAs reminded Director that parents/guardians of all children currently enrolled needed to be provided a copy of the reported dated 11/07/2024 and the signed Acknowledgement needs to be maintained in children's files for verification.

One Type A and two type B deficiencies were cited as a result of today's inspection.

Continued on Page 2
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 12/06/2024 08:42 AM - It Cannot Be Edited


Created By: Farida Raja On 12/05/2024 at 02:12 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: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
101516.5(b)(1)

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(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:
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Director to submit a written plan of correction to LPA stating how the facility will maintain ratios including back-up plans for when staff call out sick so they maintain required ratios at all times. Director to submit plan of correction by 12/06/2024.
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During today's inspection, LPAs observed 37 children with 2 staff. The facility is operating out of ratio requirements which poses an immediate health, safety or personal rights risk to persons in care. Substitute Director stated that staff called in sick and another staff is on the way.
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Civil penalty of $250 assessed during this visit.

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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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 08:42 AM - It Cannot Be Edited


Created By: Farida Raja On 12/05/2024 at 02:16 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: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
HSC
1596.8595(a)(1)

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(a)(1) Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility visit or a complaint investigation that results in a citation for a violation that, if not corrected, will create a direct and immediate risk to the health, safety, or personal rights of children in care. The licensing report provided by the department shall be posted immediately upon receipt, adjacent to the postings required pursuant to Section 1596.817 and on, or immediately adjacent to, the interior side of the main door to the facility and shall remain posted for 30 consecutive days. This requirement is not met as evidenced by:
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Director to submit statement of
understanding of Posting of Licensing Report
Requirements as per HSC1596.8595 by POC
due date of 12/06/2024.
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During today's inspection, LPAs did not observe the Facility Inspection Report including the LIC 809, LIC 809C and LIC 809D pages with the Type A citation issued on 11/07/2024 posted at the facility. This report was required to be posted for 30 days.
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Civil penalty of $100 assessed during this visit.
Type B
12/19/2024
Section Cited
HSC1596.8595(c)(4)

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Posting licensing report by child care facility or home; duration of posting; civil penalty for failure to comply; reports to be provided to parents or guardian of each child receiving services (c) (4)The licensee shall keep verification of receipt in each child's file.This requirement is not met as evidenced by:
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Licensee will submit proof of complete LIC 9224 for each child in care to CCLD by the end of business day of 12/19/2024.
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Based on observation and interview, the licensee did not comply with the section cited above by LPA observed that the Acknowledge of Receipt of Licensing Reports (LIC9224) have not been signed by the parent(s)/legal guardians.
which poses a potential health, safety or personal rights risk to persons in care.
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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: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


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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: 12/05/2024
NARRATIVE
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Civil penalties were issued for the repeat violation and for posting requirements on the attached LIC 421FC and LIC 421CC. LPA Raja informed Gloria that this report dated 12/05/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Raja informed the substitute director to provide a copy of this licensing report dated 12/05/2024 that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Appeal rights and LIC 9224 were printed and provided to substitute Director. Exit interview conducted and report was reviewed with Substitute Director, Gloria Castro.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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