434416994-9-21-2021-07-CC-SCOS-C73MSK-20210921095202

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416994
Report Date: 09/15/2021
Date Signed: 09/21/2021 09:52:14 AM

Document Has Been Signed on 09/21/2021 09:52 AM - 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 @ DEVARGAS ELEMENTARY		FACILITY NUMBER:	434416994
ADMINISTRATOR:	CECELIA GIUFFRIDA		FACILITY TYPE:	840
ADDRESS:	5050 MOORPARK AVENUE		TELEPHONE:	(925) 457-7138
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	09/15/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:	Melissa Jostedt & Cecelia Giuffida		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Pp 1 Licensing Program Analysts (LPA) Stephanie Collins conducted an announced pre-licensing inspection to the Facility today. LPA met with Area Manager Melissa Jostedt and site Director Ceclia Giufrida and explained the nature of today's inspection. The Applicant has applied for a school age license in Rooms 23, 24, 31 and 32. on the campus of De Vargas Elementary Cupertino Union School District . The school age program will operate Monday thru Friday from 06:30 AM to 8 AM - 2:05 PM to 6 PM (Tuesday 1:30 -6 PM) during school breaks and summer. A fire clearance approval for 60 school age children was received from the San Jose Fire Department prior to today's inspection. The school age program is exempt from indoor and outdoor square footage requirements, sink/toilet ratios, isolation space, and fencing requirements since it is located at a functioning public-school site. A capacity letter ( for children in Room 23,24,31,32 ) from the San Jose Fire Dept. was received prior to today's visit. LPA toured classrooms as well as the playground areas and bathrooms during today's visit. LPA observed appropriate chairs and tables for the request capacity. LPA observed a trash can with tight fitting lid and adequate equipment, furniture, and supplies for children. The children’s bathrooms are located inside rooms 31 and 32 and throughout the DeVargas Elementary School Campus allowing for individual privacy. Staff have designated bathrooms located near the main office area of the elementary school. Children who become ill can use the nurse’s station and isolation area as well as room 32 with isolation equipment.

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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 @ DEVARGAS ELEMENTARY	FACILITY NUMBER: 434416994
	VISIT DATE: 09/15/2021

NARRATIVE

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Pp 2
The Facility will provide snacks for the school age children and 5 through 12’s. Cupertino Union Schools District will supply AM and PM snacks that will be delivered to the cafeteria where staff will pick-up and bring back to classroom for distribution. There is a food preparation area with hot and cold running water a refrigerator in located in each classroom. Drinking water is provided via a combination of water fountains and water dispensers both indoors/outdoors. Cleaning supplies will be stored in a locked cabinet inaccessible to children. Transportation will not be provided by the Facility.

The program will utilize the playgrounds located throughout the elementary school campus which are fully fenced in. There is age appropriate climbing structure with sufficient resilient materials. The school age program will use the playground after public schools’ hours. Shade is provided with overhead canopies, and shaded outdoor patio area. There is adequate equipment and supplies for children outdoors. LPA did not observe any bodies of water during today's visit.
LPA did not observe any fireplaces or wall heaters at the Facility. Each room has appropriate lighting and ventilation (central heating/air conditioning). First aid supplies are stored in each room inaccessible to children. LPA observed functioning smoke detector/carbon monoxide, fully charged fire extinguisher 23A40BC.

A review of staff records on September 7, 2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded Melissa and Cecelia of the applicable $100 civil penalty per person per day, a minimum of $100.00 to a maximum of $3000.00 per person 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.

LPA discussed Senate Bill 792, AB 633, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years with Site Supervisor. Licensing forms, Title 22 regulations, can be obtained through the internet at ww.ccld.ca.gov. Mandated Reporter Training can be accessed at http://www.mandatedreporterca.com/www.mandatedreporterca.com.

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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 @ DEVARGAS ELEMENTARY	FACILITY NUMBER: 434416994
	VISIT DATE: 09/15/2021

NARRATIVE

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Pp. 3
Beginning January 1, 2019 AB 2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.

Incidental Medical Services (IMS) policy was discussed with the Applicant. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing 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)/ (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. The Applicant states that he does not plan on administering medication to the day care children at this time.

LPA conducted an exit interview ,school age license for 60 school age children will be approved upon completion of the following items:

1) Fire Clearance
2) Any required remaining documents
3) Manager’s review and approval

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

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