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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444417045
Report Date: 10/16/2024
Date Signed: 10/25/2024 01:36:41 PM


Document Has Been Signed on 10/25/2024 01:36 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 @ BROOK KNOLL ELEMENTARYFACILITY NUMBER:
444417045
ADMINISTRATOR:JORDAN ARMSTRONGFACILITY TYPE:
840
ADDRESS:151 BROOK KNOLL DRIVETELEPHONE:
(408) 624-0534
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:121CENSUS: 78DATE:
10/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Jordan ArmstrongTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Larios conducted unannounced Case Management inspection and met with Director, Jordan Armstrong. Purpose of today's inspection discuss an unusual incident that site teacher self reported to the Department on 09/26/2024. LPA observed six teachers, two assistant teachers, and seventy eight children.

LPA interviewed staff and children during today's visit. Based on interviews conducted it was determined there was inadequate supervision that is why incident was able to occur.

Deficiency and civil penalty assessed during today's inspection. See LIC 809-D for more details. Exit interview was conducted with Jordan Armstrong.

Notice of site visit was issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Elizabeth LariosTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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


Document Has Been Signed on 10/25/2024 01:36 PM - It Cannot Be Edited

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 @ BROOK KNOLL ELEMENTARY
FACILITY NUMBER: 444417045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2024
Section Cited
CCR
101229(a)(1)

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01229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1) No child(ren) shall be left without the supervision of a teacher at any time. Supervision shall include visual observation. This requirement was not met as evidence by.
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Director agreed to submit a written Plan of Correction (POC) to LPA indicating what steps will be implemented to ensure children are supervised at all times and conducted staff training, by POC due date.
***Civil penalty assessed***
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Based on interviews conducted it was determined there was inadequate supervision that is why incident was able to occur where child (C1) tided a jump rope around the neck of child (C2) and choke them. This poses a potential risk to the health and safety of children in care.
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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 SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Elizabeth LariosTELEPHONE: (408) 497-9236
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2