444417046-8-10-2022-07-CC-SYIP-CH6UY6-20220810155926

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444417046
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:59:30 PM

Document Has Been Signed on 08/10/2022 03:59 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 @ VINE HILL ELEMENTARY		FACILITY NUMBER:	444417046
ADMINISTRATOR:	ANJELICA DEL TORO		FACILITY TYPE:	840
ADDRESS:	151 VINE HILL SCHOOL ROAD		TELEPHONE:	(408) 624-0534
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	120	CENSUS: 0	DATE:	08/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Anjelica Del Toro and Brennan Bernardo		TIME COMPLETED:	12:05 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 Anjelica Del Toro and Brennan Bernardo and explained the reason for the inspection. The purpose of this inspection is 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 Vine Hill Elementary campus in Portables 4, 5, 6, and 7. A fire clearance for 120 was granted on 08/08/2022. 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. There is a board to post required postings, such as emergency disaster plan, notification of parent's rights, and car seat law. LPA toured the inside and outside of the facility. Facility plans on using Portable 6 as their main room. LPA observed that Portable 4, 5, and 7 were not set up. Portable 4 is currently being used as storage. Facility representatives stated that the cabinets and file cabinets are going to be the cabinets and the file cabinets to another room. There are toys for children in Portable 6. Anjelica stated that they will be moving shelves of toys for children. Disinfectant, cleaning supplies, and other items that are dangerous to children were observed to be inaccessible. There is fully charged fire extinguisher and smoke detector. Facility does not have carbon monoxide detector. Anjelica and Brennan stated that they will send proof of carbon monoxide detector to Licensing. Facility representatives stated that there are no weapons, such as firearms, stored on the premise. Facility will be using containers for children's belongings. -----------------------continues on 809 dated 08/10/2022 page 2---------------------------------

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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 @ VINE HILL ELEMENTARY	FACILITY NUMBER: 444417046
	VISIT DATE: 08/10/2022

NARRATIVE

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------------------------continuation of 809 dated 08/10/2022 page 1------------------------------

Facility will be using the boys and girls restroom on campus, which provides individual privacy and is separated.

The facility will be using the field area and the playground on campus. Areas around the play structure and swings have resilient materials to absorb falls. LPA observed that the resilient materials around one of the slide, rail, and the swings was low. Brennan stated that the school district is going to be refilling the tan bark by the end of the day, 08/10/2022. There were no bodies of water observed during today's inspection. Shaded rest area is provided through building overhang.

Facility will be providing snacks for the children. There is menu posted. Drinking water is provided through water fountains, water bottle fillers, and individual water bottles.

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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. 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

Facility will transfer fingerprints to facility number. 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

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SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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 @ VINE HILL ELEMENTARY	FACILITY NUMBER: 444417046
	VISIT DATE: 08/10/2022

NARRATIVE

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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:
- carbon monoxide detector
- picture of Portable 4, 5, and 7
- Proof of purchase of scissor and adhesive tape for the First Aid Kit
- Proof of tight-fitted trash can
- Tan bark is refilled around play structure and swings

Exit interview conducted and report was reviewed with the facility representatives Anjelica Del Toro and Brennan Bernardo. 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

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

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