434416994-5-16-2024-07-CC-SYIP-D5C3MT-20240516182250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416994
Report Date: 05/16/2024
Date Signed: 05/16/2024 06:23:05 PM

Document Has Been Signed on 05/16/2024 06:23 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 @ DEVARGAS ELEMENTARY		FACILITY NUMBER:	434416994
ADMINISTRATOR/ DIRECTOR:	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: 28	CENSUS: 22	DATE:	05/16/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:35 PM
MET WITH:	Diana Lozano and Adela Bjelevac		TIME VISIT/ INSPECTION COMPLETED:	04:55 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	Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced annual/random inspection. LPA met with Site Director Diana Lozano and explained the reason for the inspection. Area Manager, Adela Bjelevac, arrived shortly after. The center is located on the DeVargas Elementary School campus. The center currently only uses Room 32. Present during today's inspection were at least three staff and 20 children. Facility was within ratio during today's inspection. There is an area to post required postings, such as license and notification of parents. There is working phone on site. LPA reviewed the sign in/out sheet. LPA toured the inside and outside with Director and Area Manager. All disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible to children. There are toys and equipment for children. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Director stated that there are no weapons, such as firearms, stored on the premise. The outside area is fenced. Area around play structure have resilient material. Shaded rest area is provided through building overhang. There were no bodies of water observed during today's inspection. The center does provide snacks to children. A menu was observed to be posted. LPA discussed with Area Manager that the center needs to provide at least two food groups during snack. Drinking water is provided through individual water bottles and water fountain. -----------------------continues on 809 dated 05/16/2024 page 2-------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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 @ DEVARGAS ELEMENTARY	FACILITY NUMBER: 434416994
	VISIT DATE: 05/16/2024

NARRATIVE

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--------------------continuation of 809 dated 05/16/2024 page 1-------------------

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.

Director and Area Manager stated that the building was built after 01/01/2010. They stated that they submit proof that the building was built after 01/01/2010 and submit it to Licensing.

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/.

A copy of the facility roster was obtained during today's inspection. Four children's files were reviewed during today's inspection. The records reviewed include but not limited to notification of parent's right.

Three staff files were reviewed during today's inspection. The records reviewed include but not limited to education credit and mandated reporter training. Director has a valid CPR/1st Aid, which expires on 01/2025.

--------------------continues on 809 dated 05/16/2024 page 3-------------------------

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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: 05/16/2024

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--------------------continuation of 809 dated 05/16/2024 page 2------------------

S-1 was present during today's inspection. S-1 has cleared criminal record and child abuse index, but fingerprints were disassociated from the facility. Area Manager transfer fingerprints during today's inspection. Facility representative 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.

Center will submit the following to Licensing:
- proof that building is built after 01/01/2010 by 05/24/2024
- Director's packet by 06/14/2024
- facility roster (LIC 9040)
- snack menu that shows two food groups

As a result of this inspection, a Type A citation was issued. A civil penalty of $500 was assessed for caregiver background check. Exit interview conducted and report was reviewed with Area Manager Adela Bjelevac. A notice of site visit was issued and must remain posted for 30 days.

LPA Samantha Yip informed Area Manager, Adela Bjelevac, that this report dated 05/16/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed Area Manager to provide a copy of this licensing report dated 05/16/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2024 06:23 PM - It Cannot Be Edited

Created By: Samantha Yip On 05/16/2024 at 04:12 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 @ DEVARGAS ELEMENTARY	FACILITY NUMBER: 434416994
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

101170(e)(2)

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 101170(f)... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited, which posed an immediate health, safety or personal rights risk to persons in care. S-1 has cleared criminal record and child abuse index, but fingerprints were disassociated.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Deficiency was cleared during today's inspection. Area Manager associated S-1's fingerprint during today's inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Samantha Yip

LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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