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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414261
Report Date: 01/15/2025
Date Signed: 01/16/2025 08:34:27 AM

Document Has Been Signed on 01/16/2025 08:34 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: 30DATE:
01/15/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:09 PM
MET WITH:Jacob Corona and Meliza ViverosTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 01/15/2025 at 3:09pm, Licensing Program Analyst (LPA), Farida Raja conducted an unannounced case management inspection. LPA met with Staff, Jacob Corona and explained the purpose of today's visit. Director, Meliza Viveros arrived shortly.

During today's inspection, LPA observed 30 children and 3 staff. Facility is operating within ratio requirements.

LPA reviewed 10 children's files for the Acknowledgement of Receipt of Licensing Reports (LIC 9224) for the Type A deficiencies cited on 11/07/2024 and 12/05/2024. Children were observed to have the LIC 9224s on file. LPA reminded Director that parents/guardians of all children enrolling in the next 12 months from 11/07/2024 and 12/05/2024 need to be provided a copy of the respective reports and the signed Acknowledgement needs to be maintained in children's files for verification.

Upon review of staff files, LPA observed that staff, S1 and S2 have fingerprint clearances but the clearances have not been transferred to this facility. LPA observed that staff S2 is missing result of tuberculosis test and immunization's for pertussis and measles.

Three Type B deficiencies cited as a result of today's inspection. Appeal rights provided.

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

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: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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
Document Has Been Signed on 01/16/2025 08:34 AM - It Cannot Be Edited


Created By: Farida Raja On 01/15/2025 at 04:39 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: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
CCR
101170(e)(2)

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or
This requirement is not met as evidenced by:
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Director to submit plan of correction to LPA by 01/29/2025.
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Based on file review, LPA observed that staff, S1 and S2 have fingerprint clearances but the clearances have not been transferred to this facility. This poses a potential risk to the health, safety and personal rights of children in care.
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Type B
01/29/2025
Section Cited
CCR101216(g)(1)

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Personnel Requirements (g) All personnel... shall be in good health and shall be physically and mentally capable of performing assigned tasks. (1)... good physical health shall be verified by a health screening, including a test for tuberculosis, performed by... a physician not more than one year prior to or seven days after employment or licensure.This requirement is not met as evidenced by:
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Director to submit proof of negative tuberculosis test and a plan of correction to LPA by 01/29/2025.
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Based on file review, LPA observed that staff, S2 is missing proof of negative tuberculosis test. This poses a potential risk to the health, safety and personal rights of children 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: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/16/2025 08:34 AM - It Cannot Be Edited


Created By: Farida Raja On 01/15/2025 at 04:45 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: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
HSC
1596.7995(a)(1)

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(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
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Director to submit proof of missing immunizations for staff, S2 and a plan of correction to LPA by 01/29/2025.
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Based on file review, LPA observed that staff, S2 is missing proof of immunizations for measles and pertussis. This poses a potential risk to the health, safety and personal rights of children 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: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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