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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416987
Report Date: 07/12/2022
Date Signed: 07/12/2022 04:00:33 PM

Document Has Been Signed on 07/12/2022 04:00 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:
434416987
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:19621 BLACK ROADTELEPHONE:
(408) 348-1610
CITY:LOS GATOSSTATE: CAZIP CODE:
95033
CAPACITY: 30TOTAL ENROLLED CHILDREN: 16CENSUS: 13DATE:
07/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Angela NelsonTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Mel Matos and Araceli Almaraz met with Angela Nelson, director, for an unannounced case management inspection. Purpose of today's investigation: address Unusual Incident that the Facility reported to the Department.

LPAs interviewed two staff and reviewed facility documents during today's inspection.

Further investigation is required and LPAs will follow up at a later date to conduct additional interviews.

No deficiencies issued during today's inspection.


Notice of site visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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