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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416987
Report Date: 07/21/2022
Date Signed: 07/21/2022 04:34:18 PM

Document Has Been Signed on 07/21/2022 04:34 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: 14DATE:
07/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Angela NelsonTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Mel Matos met with Angela Nelson, director, for an unannounced case management inspection. Purpose of today's investigation: follow up on an Unusual Incident that the Facility reported to the Department. LPA's initial inspection was completed on July 12, 2022.

The Unusual Incident occurred on June 15, 2022 where there was a potential lapse of supervision during a group activity in the Community Center.

LPA interviewed one school age child during today's inspection.

Based on the available evidence and interviews completed, LPA concludes that there is insufficient evidence to prove that a lapse of supervision occurred. Exit interview conducted and report was reviewed with Angela Nelson, director.

No deficiencies issued during today's inspection. A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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