434417042-8-13-2024-07-CC-SYIP-D84VN5-20240813163435

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417042
Report Date: 08/13/2024
Date Signed: 08/13/2024 04:34:41 PM

Document Has Been Signed on 08/13/2024 04:34 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 @ DILWORTH ELEMENTARY		FACILITY NUMBER:	434417042
ADMINISTRATOR/ DIRECTOR:	JUANA LIZABETH VILLALOBOS		FACILITY TYPE:	840
ADDRESS:	1101 STRAYER DRIVE		TELEPHONE:	(408) 386-5745
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY: 120	TOTAL ENROLLED CHILDREN: 55	CENSUS: 0	DATE:	08/13/2024
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:53 PM
MET WITH:	Adela Bjelevac and Juana Lizbeth Villalobos		TIME VISIT/ INSPECTION COMPLETED:	04:40 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 Analysts (LPAs) Samantha Yip and Jennifer Beehler conducted an unannounced Case Management- Licensee Initiated inspection. LPA met with Area Manager Adela Bjelevac and Director Juana Lizbeth Villalobos and explained the reason for the inspection. The purpose of this inspection is the center is requesting a change of rooms from Room 22 and 23 to Room 30, 31, and 32. The center is located on the Dilworth Elementary School campus. An updated fire clearance was granted on 08/07/2024. There is an area to post required postings, such as license, notification of parent's rights, car seat, and personal rights. The center has a cell phone that they will use. LPAs toured the inside and outside of the facility. All disinfectant, cleaning supplies, and other items that could pose a risk to children were inaccessible. There are toys for children. There are 14 tables, 85 chairs, and 96 hooks. There are two additional tables and 36 additional chairs in Room 29, which is used as storage. Area Manager understands that there needs to be a hook and chair for each child. She stated that they only have 50 children currently enrolled. Bathroom for children provides individual privacy and was in functioning condition. There is a girls and boys bathroom located next to Room 17, which also provides individual privacy. 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 center will use Room 32 to isolate any sick children and the restroom located in Room 32. ----------------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)

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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 @ DILWORTH ELEMENTARY	FACILITY NUMBER: 434417042
	VISIT DATE: 08/13/2024

NARRATIVE

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-------------CONTINUATION OF 809 DATED 08/13/2024 PAGE 1---------------

The center will be using the playground and blacktop area that is next to Room 28. There is play structure that had tan bark around it. LPAs observed that there are some areas where the tan bark was low. The center will also being using the playground area that is next to Room 1. There is resilient material around playstructure. LPA observed that there is about a 6 inch gap between the fence and the ground and that one of the sensory tables is broken. Both play structures are designated for ages 5 to 12 years old. The center is requesting a license for 4.9 years to 14 years old. The center understands that the children under 5 years old cannot use the play structure. Area Manager submitted proof of purchase for a playstructure that is for ages 1-6 years old. Playstructure will be placed in the grass and patio area in front of the rooms. Director stated that the youngest child they have enrolled is 5 years old. Shaded rest areas are provided by trees and building overhang. There were no bodies of water observed during today's inspection.

The center only provides pre-packaged snacks to children. There is a menu posted. There is a fridge to store any perishable food. Drinking water is provided through water bottles and individual water bottles.

The center will submit the following:
- proof of additional hooks
- letter from the school district regarding changes to room
- additional tan bark in the yard next to Room 28

As a result of this inspection, no deficiencies were issued. Exit interview conducted and report was reviewed with Area Manager, Adela Bjelevac and Director Lizbeth Villalobos. A notice of site visit was issued and must remain posted for 30 days. Area Manager and Director was advised that upon completion of the above items that an updated license will be issued to reflect the change to the room.

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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