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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416987
Report Date: 01/25/2024
Date Signed: 01/25/2024 04:05:03 PM

Document Has Been Signed on 01/25/2024 04:05 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: 25CENSUS: 17DATE:
01/25/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Gretchen JacobsonTIME COMPLETED:
04:15 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. Upon arrival, there were four (4) TK children and one (1) staff member present, which is compliant with the facility license capacity and ratio requirements. Once school was dismissed, there were seventeen (17) school-age children and one additional staff member, Justin, present. LPA observed all required postings near the entrance to the facility and the hours of operation for the facility are Monday – Friday, 7:00AM-8:00AM (before school) and 1:15PM-6:00PM (after school).

LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. Sign-in/out was observed to be completed with full legal signature and time of day. The last fire/disaster drill was conducted 9/2023, which is compliant with the six-month requirement for facilities. LPA observed a fully charged 2A10BC fire extinguisher (last serviced: 6/2022) and functioning carbon monoxide detector. The building has a built in fire detection system. The Site Director states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. There are no weapons or firearms on the premises.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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/.
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.

LIC809 (FAS) - (06/04)
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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: 434416987
VISIT DATE: 01/25/2024
NARRATIVE
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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. The floors were clean and free of tripping hazards. Drinking water is readily available for children via water dispensers and disposable cups in addition to water bottles from home. The children in care use the Lakeside Elementary School bathrooms and LPA observed that they are clean, sanitary, and operable. There is a working telephone in the facility.

The outdoor area of the facility was inspected and observed to be fenced in. The facility utilizes the Lakeside Elementary School playground that is in good repair and age appropriate for the children in care. LPA observed there is sufficient resilient materials (tanbark) to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by large trees and building overhang.

The facility offers a half day program and provides AM and PM snack to children. The Site Director states that food served to the school-age children is brought from the preschool room prior to snack being served. The Site Director further states that Lakeside Elementary School has specifically requested that the facility does not store food in the music room (rm: 402). The snack menu is in writing and posted at least one week in advance, accessible to authorized representatives. LPA advised that snack shall at a minimum contain two food groups and the menu shall include portion sizes.

Five (5) children’s files were reviewed and all required documents were present.

Three (3) staff files were reviewed and all required documents were present. The Site Director 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.
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: 434416987
VISIT DATE: 01/25/2024
NARRATIVE
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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 did not complete testing prior to their deadline and the Site Director has indicated that the facility does not use any faucets for food prep or drinking water. LPA advised following directives of PIN 21-21.1-CCP for submitting attestation that the facility does not use faucets for food prep or drinking water and is exempt from water lead testing.

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.

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.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
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
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/25/2024 04:05 PM - It Cannot Be Edited


Created By: Cortney Nelson On 01/25/2024 at 03:02 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 @ LAKESIDE ELEMENTARY
FACILITY NUMBER: 434416987

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101170(e)(2)
101170 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall priro to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specificed in Section 101170(f).

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 for one staff member present today, subbing from another Champions center, 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 Site Director shall submit transfer requests (LIC9182) for any substitute staff that may assist at the facility and submit to the Department by 1/26/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: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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Document Has Been Signed on 01/25/2024 04:05 PM - It Cannot Be Edited


Created By: Cortney Nelson On 01/25/2024 at 03:43 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 @ LAKESIDE ELEMENTARY
FACILITY NUMBER: 434416987

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 water lead testing was not completed for the facility, 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 facility for any faucets that are used for food prep or drinking water following the directives of PIN 21-21.1-CCP. If the facility does not use any faucets for food prep or drinking water, a self attestation shall be submitted for exemption from the requirement.
Type B
Section Cited
CCR
101227(a)(1)
Food Service
(a) In child care centers providing meals to children, the following shall apply: (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 not all snacks provided include at least two food groups, 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 snack menu for February that reflects at a minimum two food groups for snack served to children and shall be submitted to the Department by 2/5/2024.
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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