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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416986
Report Date: 08/05/2021
Date Signed: 08/09/2021 02:03:58 PM

Document Has Been Signed on 08/09/2021 02:03 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:
434416986
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
850
ADDRESS:19621 BLACK ROADTELEPHONE:
(408) 348-1610
CITY:LOS GATOSSTATE: CAZIP CODE:
95033
CAPACITY: 18TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/05/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Tamara Payne-AlexTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA), Stephanie Collins met Program Director Tamara Payna-Alex. Applicant representative for KCE Champions LLC. is applying for a Preschool license at the address listed above. The requested capacity is 18 Preschool children ages 3 to 5 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 The Preschool program and School Age Program - A M drop-offs and P M pick-ups. The 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:
Preschool Indoor active space:
Preschool room
= (Total sq. ft.) – (Total Encumbered Space) = ( 892.5.) -(33. sq. ft.)
= 858.925 sq. ft.

Total Indoor Activity Space = (858.924.) divided by (35 sq. ft) = 24 / children


Preschool outdoor activity Space = (6,545.744 sq. ft.) divided by (75 sq. ft. / child) = 87 Preschool Age children
There are 8/120 toilet and 5/75 sinks accessible to preschool 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: 434416986
VISIT DATE: 08/05/2021
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LPA observed that the preschool yard is fully enclosed by fencing. 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. Water is provided by water coolers and children are encourage to bring water bottles. There are staff restrooms in the common area of school. There is a designated area in class room that can be used to isolate a sick child who becomes ill and isolation equipped is available. The Preschool 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 snack and parents are ask to bring lunches. Menu is posted. LPA observed trash cans with tight fitting covers for the disposal of solid waste. food can be refrigerated and heated if necessary

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: 2 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: 434416986
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: 3 of 3