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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416994
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:45:22 PM

Document Has Been Signed on 08/13/2024 03:45 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 ELEMENTARYFACILITY NUMBER:
434416994
ADMINISTRATOR/
DIRECTOR:		CECELIA GIUFFRIDAFACILITY TYPE:
840
ADDRESS:5050 MOORPARK AVENUETELEPHONE:
(925) 457-7138
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 0DATE:
08/13/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:17 PM
MET WITH:Adela Bjelevac and Diana LozanoTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Samantha Yip and Jennifer Beehler conducted an unannounced Case Management-Licensee Initiated inspection. LPA met with Area Manager, Adela Bejelevac, and Diana Lozano and explained the reason for the inspection. The purpose of the inspection is facility is changing rooms to Room 21, 22, and 24 only. Facility is currently licensed in Room 24. The center is located on the Devargas Elementary School campus. An updated fire clearance was granted on 08/07/2024.

There is area to post required postings, such as license, notification of parent's rights, personal rights, and car seat in Room 24. There is a cell phone that the center uses.

LPA inspected the rooms. There are 12 tables, 64 chairs, and 106 hooks. There are toys for children. LPA discussed with Area Manager and Director that all cleaning supplies needs to be inaccessible to children. There is a boys and girls restroom, which were in functioning condition and provides individual privacy. Center will use the area in Room 22 that is across from the girls' restroom to isolate any sick children. The center will use one of the stalls in the girls' restroom for sick children. The center understands that they cannot use the same restrooms as other program on site. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. Area Manager stated that there are no weapons, such as fire arms, stored on the premise.

----------------------continues on 809 dated 08/13/2024 page 2---------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 08/13/2024
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--------------------continuation of 809 dated 08/13/2024 page 1-------------------

The center will use the playground and picnic area that is between Room 1 and 30. Area around play structure has resilient material. Shaded rest area is provided through building overhang. There were no bodies of water observed during today's inspection. The center understands that they need to notify Licensing if they want to use the playground area off of Room 29. Licensing would need to inspect the area and approve it prior to the center being able to use it.

The center only provides pre-packaged food to the children. Snack menu was observed to be posted. There is a fridge to store perishable food. Drinking water will be provided by water bottles and individual water bottles. There are water fountains outside, which they stated was tested by the school district and will not be used. Center understands that they need to test water if the sink or the water fountains are going to be used by the children.

The center will submit the following by 08/16/2024:
- updated LIC 999: Yard
- letter from the school district regarding changes to the room

As a result of this inspection, no deficiencies were issued. Exit interview was conducted and report was reviewed with Area Manager, Adela Bejelevac, and Diana Lozano. Facility was advised that the physical plants were approved and an updated license will be mailed to the center. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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