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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416986
Report Date: 01/25/2024
Date Signed: 01/25/2024 12:19:06 PM

Document Has Been Signed on 01/25/2024 12:19 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: 5CENSUS: 2DATE:
01/25/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Gretchen JacobsonTIME COMPLETED:
12:29 PM
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Licensing Program Analyst (LPA), Cortney Nelson, met with Site Director, Gretchen Jacobson, for an unannounced Required- 3 Year Inspection. LPA was granted access to the facility by staff member, Jessika, and toured both indoors and outdoors during the inspection. Site Director Gretchen arrived to the facility around 10:00AM. Upon arrival, there was one preschool-age child and one staff member present, which is compliant with the facility license capacity and ratio requirements. A second child arrived to the facility shortly after Gretchen's arrival. LPA observed all required postings near the entrance to the facility and the hours of operation are Monday – Friday, 8:00AM-6:00PM.

The facility currently has an active waiver for shared bathroom use with Lakeside Elementary School and commingling of the school-age and preschool program during specified hours of the day. LPA received waiver request from Gretchen to amend the hours of commingling to match the current program hours.

LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. LPA advised that sign-in/out shall be completed with full legal signature by the representative dropping the child off. Sign-in/out was observed to be completed by staff and with parents signing "mom" or "dad" which does not meet regulation requirements. The last earthquake drill was conducted 12/2023, which is compliant with the six-month requirement for facilities. LPA observed a fully charged 3A40BC fire extinguisher (last serviced: 6/2023) and functioning carbon monoxide detector. The facility has a built in fire detection system. There is a child in care who require Incidental Medical Services (EpiPen) and non-prescription medication. LPA advised that EpiPens shall be stored inaccessible to children, however shall not be locked due to the time sensitive nature of using the medication. There are no weapons or firearms on the premises.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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
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: 01/25/2024
NARRATIVE
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and
administrative records. For IMS information see PIN 22-02-CCP. 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/.

Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via water dispensers and disposable cups. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children, which an isolated child can use if necessary. There is a working telephone in the facility.

The outdoor area of the facility was inspected and observed to be fenced in. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials to absorb falls. There are plastic vehicles, climbing structures, balls, and plastic houses for the children to play with. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by large trees and building overhang.

Food is provided by the facility and is stored, prepared, and served in a safe and healthful manner to the children. The facility offers a full day program and provides AM and PM snack to the children. The menu is in writing and posted at least one week in advance, accessible to authorized representatives. LPA advised that snacks shall at a minimum include two food groups as not all snack's provided meet that requirement. LPA additionally advised including portion sizes of food served on the menu. The kitchen and storage area is clean and free of litter and rubbish. Knives were observed to be in an unlocked drawer in the kitchen, which is accessible to children, and advised that knives and other sharp objects shall be stored locked or inaccessible to children. Knives were relocated in a basket on top of the fridge during today's inspection. Equipment necessary for the storage, preparation and service of food is well maintained, clean, and sanitized after each use.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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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
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: 01/25/2024
NARRATIVE
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Five preschool children’s files were reviewed during today’s inspection and all required documents were present. LPA reminded that physicians report shall be completed within 30 days of enrollment for newly enrolled children.

Two staff files were reviewed and all required documents were present. LPA advised that changes in the Site Director shall be reported to the Department within 10 days as there was no notification of Gretchen Jacobson starting as Director. LPA reviewed Gretchen's file and observed she is Site Director qualified. Gretchen has current CPR/First-Aid that expires 7/2024 and Mandated Reporter Training that expires on 6/9/2024. LPA reminded that the Mandated Reporter Training must be renewed by all staff every 2 years.

Licensee 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.

The site director understands that she shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded 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, such as field trips.

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. The facility has not completed testing prior to the deadline and LPA advised completing water lead testing for the facility.

Exit interview conducted and report was reviewed with the Site Director, Gretchen Jacobson.

As a result of today’s inspection, deficiencies were cited, see LIC809-D

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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Document Has Been Signed on 01/25/2024 12:19 PM - It Cannot Be Edited


Created By: Cortney Nelson On 01/25/2024 at 11:34 AM
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 @ LAKESIDE ELEMENTARY
FACILITY NUMBER: 434416986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the facility has not completed water lead testing for the faucets used for food prep, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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The facility shall schedule water lead testing for the faucets used for drinking water or food prep and follow the directives indicated in PIN 21-21.1-CCP, including submitting facility sketch with faucets identified, and LIC9275/LIC9276.
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to 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 as two knives and a pizza cutter were located in a unlocked drawer that can be accessed by children, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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The knives and pizza cutter have been relocated to a basket located on top of the refrigerator. LPA advised other locations that would be appropriate for the sharp objects to be placed, such as locking the drawer or placing in a cabinet that is fully inaccessible to children.
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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2024 12:19 PM - It Cannot Be Edited


Created By: Cortney Nelson On 01/25/2024 at 11:34 AM
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 @ LAKESIDE ELEMENTARY
FACILITY NUMBER: 434416986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as two out of five children have parent's signing in with "mom" or "dad" instead of their full legal signature, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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The facility will remind parents that full legal signature shall be used when signing children in/out of the facility and submit proof of proper sign-in/out to the Department for five children enrolled on 2/2/2024.
Type B
Section Cited
CCR
101229.1(b)
Sign In and Sign Out
(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as staff member, Jessika, has been observed to sign children in upon arrival for two out of five children, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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The facility will remind parents that signature is required upon drop off and pick up and that staff shall not be responsible for signing children in upon arrival. Sign-in/out sheets for five children enrolled shall be submitted to the Department on 2/2/2024 to demonstrate proper sign-in/out procedures.
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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2024 12:19 PM - It Cannot Be Edited


Created By: Cortney Nelson On 01/25/2024 at 11:34 AM
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 @ LAKESIDE ELEMENTARY
FACILITY NUMBER: 434416986

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101212(b)
Reporting Requirements
(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in as the Department was not notified that Gretchen Jacobson is the Site Director, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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The facility shall submit Director's packet for Gretchen Jacobson, including revised Application for a Child Care Center (LIC200A) completed for preschool and school-age program, to the Department by 2/5/2024. Any future Director changes shall be reported to the Department within 10 days.
Type B
Section Cited
CCR
101227(a)(1)
Food Service
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the children. Each meal shall include, at a minimum, the amount of food components as specified by Title 7, Code of Federal Regulations, Part 226.20, (Revised January 1, 1990) Requirements for Meals, for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 as snacks served to children do not include at least two food groups and portion sizes are not indicated, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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The snack menu for February shall be submitted to the Department by 2/5/2024 and demonstrate that snack served to children includes at least two food groups. Portion sizes to be included or a reference chart to be placed next to the snack menu.
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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


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