444417045-6-12-2024-07-CC-BDEL-D89KYJ-20240818081912

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 444417045
Report Date: 06/12/2024
Date Signed: 06/12/2024 01:15:45 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2024 and conducted by Evaluator Melvin S Matos

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20240610161443

FACILITY NAME:	KCE CHAMPIONS LLC @ BROOK KNOLL ELEMENTARY		FACILITY NUMBER:	444417045
ADMINISTRATOR:	SARAH HINKLE		FACILITY TYPE:	840
ADDRESS:	151 BROOK KNOLL DRIVE		TELEPHONE:	(408) 624-0534
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	121	CENSUS: 72	DATE:	06/12/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Stephanie "Stellman" Greene		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Notice of Site Visit not posted

Staff not associated to the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mel Matos met with Stephanie "Stellman" Greene, interim director, for an unannounced 10 day complaint investigation. Today's investigation was conducted in the Rec Portable Unit of the Facility. LPA toured the room, reviewed staff files, and interviewed Stephanie (on site) and Anjelica Del Toro, area manager, via telephone, for this investigation.

Based on interviews, record reviews, observations, and evidence gathered during the investigation process, the Department concludes that the notice of site visit from the Department's last visit to the Facility on June 4, 2024 was not posted upon LPA's arrival to the Facility and Staff 2 (S2) & Staff 7 (S7) began working at the Facility on Monday June 10, 2024, but were not associated to the Facility until 06/11/2024 (S2) and June 12, 2024 (S7). The allegations noted above are thus found to be SUBSTANTIATED, meaning the allegations are valid because the preponderance of the evidence standard has been met.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 07-CC-20240610161443

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KCE CHAMPIONS LLC @ BROOK KNOLL ELEMENTARY	FACILITY NUMBER: 444417045
	VISIT DATE: 06/12/2024

NARRATIVE

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Two "Type B" deficiencies are being cited on the attached LIC 9099-D. Civil penalties of $100 (failure to comply with posting requirements) - LIC 421CC - and $300 (allowing staff to work at the Facility without a clearance transfer) - LIC 421BG - were assessed during today's complaint investigation.

Exit interview conducted and report was reviewed with the Director, Stephanie "Stellman" Greene. Appeal rights was also provided to Director prior to conclusion of today's investigation.

Notice of site visit was issued and posted by Director prior to the conclusion of today's investigation. LPA reminded Director that the notice of site visit must remain posted for 30 days

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 07-CC-20240610161443

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 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: 06/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/12/2024 Section Cited HSC 1596.817(b)(2)	1 2 3 4 5 6 7	Site visits; posting of notices; contents; citations for violations; duration of posting; civil penalties: Notice of site visit shall remain posted for 30 consecutive days and failure to post shall result in an immediate civil penalty of $100.	1 2 3 4 5 6 7	Director, Stephanie "Stellman" Greene located the notice of site visit and immediately posted the notice of site visit. $100 immediate civil penalty issued today.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: the Notice of Site Visit from the Department's last visit to the Facility on June 4, 2024 was not posted upon LPA's arrival to the Facility.	8 9 10 11 12 13 14	Deficiency cleared.
Type B 06/17/2024 Section Cited CCR 101170(e)(2)	1 2 3 4 5 6 7	Criminal Record Clearance: 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)	1 2 3 4 5 6 7	Anjelica Del Toro, area manager, agreed to submit a written Plan of Correction (POC) listing what step(s) are going to be implemented to ensure that all staff have clearances
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Staff 2 (S2) & Staff 7 (S7) began working at the Facility on Monday June 10, 2024, but were not associated to the Facility until 06/11/2024 (S2) and June 12, 2024 (S7)	8 9 10 11 12 13 14	transferred/associated to a licensed site(s) prior to allowing staff to start working. $300 immediate civil penalties issued today.

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: Belinda Devall	TELEPHONE: (408) 598-5501
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC9099 (FAS) - (06/04)

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