<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417042
Report Date: 08/15/2022
Date Signed: 08/16/2022 09:30:49 AM

Document Has Been Signed on 08/16/2022 09:30 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 @ DILWORTH ELEMENTARYFACILITY NUMBER:
434417042
ADMINISTRATOR:LUCY GANNERFACILITY TYPE:
840
ADDRESS:1101 STRAYER DRIVETELEPHONE:
(925) 457-7138
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 0DATE:
08/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Melissa Jostedt and Lucy GannerTIME COMPLETED:
01:55 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 announced pre-licensing inspection. LPA met with Melissa Jostedt, facility representatives, and explained the reason for the inspection. The purpose of this inspection is the Applicant, KCE Champions LLC, is applying for a school-age license with a capacity of 120, serving ages 4.9 to 14 years old. Facility is located on the Dilworth Elementary campus in Room 22 and Room 23. A fire clearance for 120 was granted on 06/07/2022.

Since this School-Age Center will be operating on a functioning school site, the Center is exempt from requirement of square-footage for indoor and outdoor activity space, and toilet, fencing, and isolation space requirements for child day care centers, pursuant to Health and Safety Code Section 1596.806. Facility understands that they cannot exceed the capacity approved for the room.

There is board to post required postings, such as notification of parent's rights. LPA discussed with Melissa and Lucy about the required postings, such as menu, daily activity schedule, personal rights, car seat law, and facility sketch. The hours of operation are Monday through Friday 6:30AM to 6PM. There is working phone at the facility; (408) 386-5745.

LPA toured in the inside and outside of the facility. Facility has hooks for children's belongings. Disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible to children. LPA observed that there are tables and chairs for children. There are toys for children. Facility is still in the process of setting up the rooms. Facility will send picture of completed rooms to Licensing once completed. There is fully charged fire extinguisher and smoke detector. Facility will be obtaining a

----------------------------continues on 809 dated 08/15/2022 page 2-----------------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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 3
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 @ DILWORTH ELEMENTARY
FACILITY NUMBER: 434417042
VISIT DATE: 08/15/2022
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
26
27
28
29
30
31
32
-----------------------------continuation of 809 dated 08/15/2022 page 1-----------------------

carbon monoxide detector and send proof to Licensing. There is a first aid kit, but is missing a tweezer and a thermometer. Melissa stated that there are no weapons, such as firearms, stored on the premise. Bathroom for children provide individual privacy and is separated. Facility will also be using the girls and boys restroom next to the school-age structure. There is one toilet in the boy's restroom inside the room that does not flush. Facility will be fixing the toilet. There is a sink in each of the rooms. LPA observed that the hinge on the cabinet below the sink in Room 23 is loose. Facility will fix the cabinet. Isolation area will be in front of the windows in Room 22 #2 and Room 23 #2.

Facility will be using the school-age structure and the kinder structure. Shaded rest area is provided through building overhang, canopy, and trees. Areas around play structure have resilient material. LPA observed that there were areas below the slides, steps, and monkey bars where the resilient material was low. Melissa stated that she will send proof that resilient material is even. LPA also observed that there are overgrown weeds on the school-age structure. LPA discussed with Melissa about the wooden steps in the kinder structure is starting to wear and one of the panels is starting to get uneven. Play structures in the school-age and the kinder structure are for ages 5 to 12 years old. LPA discussed with Melissa and Lucy about ensuring children meet the age for the play structure. There were no bodies of water observed during today's inspection.

Facility will be providing snacks for children. There is a fridge to store food. Drinking water is provided through water fountains. Facility purchased a tight-fitted trash can.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. LPA reminded Melissa that any medication needs to inaccessible to children. A 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)/ (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

------------------------continues on 809 dated 08/15/2022 page 3-------------------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 @ DILWORTH ELEMENTARY
FACILITY NUMBER: 434417042
VISIT DATE: 08/15/2022
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
26
27
28
29
30
31
32
-----------------------continuation of 809 dated 08/15/2022 page 2-------------------------------
Facility does not plan on transporting children.

LPA reviewed with facility representative the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Facility representatives were reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Facility will submit the following:
- proof of carbon monoxide detector
- Tweezer and thermometer for First Aid Kit
- weeds in the school-age structure are cleared
- tan bark in the school-age structure and kinder structure are even
- picture of Room 22 and Room 23 set up
- tight-fitted trash can
- cabinet below the sink in Room 23 is fixed

Exit interview conducted and reported was reviewed with Facility Representatives, Melissa Jostedt, and Site Director Lucy Ganner. LPA advised facility representatives upon approval of Licensing Management, a license for a school-age center will be granted and issued to Applicant and completion of the following:
- proof of carbon monoxide detector
- proof of tight-fitted trash can
- picture of rooms set up
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3