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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444417046
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:31:55 PM


Document Has Been Signed on 10/19/2023 04:31 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 ELEMENTARYFACILITY NUMBER:
444417046
ADMINISTRATOR:STEPHANIE STELLMANFACILITY TYPE:
840
ADDRESS:151 VINE HILL SCHOOL ROADTELEPHONE:
(408) 624-0534
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:120CENSUS: 80DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Stephanie StellmanTIME COMPLETED:
04:41 PM
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Licensing Program Analyst (LPA), Cortney Nelson, met with Site Director, Stephanie Stellman, for an unannounced Required- 1 Year Inspection. LPA was granted access to the facility by the Site Director and toured both indoors and outdoors during the inspection. The facility is located at Vine Hill Elementary School and TK/kindergarteners were observed in room P6 and 1st-5th in the Champions Before and After School Portable. Present at the facility today were eighty (80) school-age children and eight (8) staff, which is compliant with capacity and ratio requirements. LPA observed all required postings near the entrance to the facility and the hours of operation are Monday – Friday, 6:30AM-8:30AM/11:50AM-6:00PM.

LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. Sign-in/out was observed to be completed by Champions staff members upon arrival and by parents/guardians for sign-out and all were completed with full legal signature and time of day. The last fire/disaster drill was conducted on 4/25/2023, which is compliant with the six-month requirement for facilities. LPA observed three fully charged 3A40BC fire extinguishers, built in fire/smoke detector, and carbon monoxide detector. LPA advised adding a carbon monoxide detector to the main portable room. Stephanie states that she currently has children in care who require Incidental Medical Services (EpiPens) and observed medication is properly stored out of reach of children with the proper documentation. LPA advised that physicians note for IMS shall be provided to the facility in addition to the elementary school. All medication were observed to be expired and LPA advised monitoring medication for expiration date. There are no weapons or firearms on the premises.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and
administrative records.
For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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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Document Has Been Signed on 10/19/2023 04:31 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 @ VINE HILL ELEMENTARY
FACILITY NUMBER: 444417046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
WD
100700(c)(1)
Written Directives for Lead Testing
(1) For a license issued on or after July 1, 2022, initial testing results shall be received and posted within 180 days of licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as it has been more than 180 days since the facility received a license, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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The facility shall schedule water lead testing and follow the Written Directives outlined in PIN 21-21.1-CCP. Proof of scheduled water lead testing shall be submitted to the Department by 11/1/2023.
Type B
Section Cited
CCR
101226(e)(5)
101226 Health-Related Services (e)(5) The Licensee shall develop and implement a written plan to record the administration of prescription and non prescription medications and to inform the child's authorized representative daily when such medications have been given.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as three out of three medications stored at the facility were expired, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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The Site Director shall return expired medication to children and obtain current medication. A plan of correction outlining how medication expiration dates will be monitored shall be submitted to the Department by 10/23/2023.
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: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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: 10/19/2023
NARRATIVE
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Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Drinking water is readily available for children via water dispensers and disposable cups/water bottles. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children, which an isolated child can use if necessary. There is a working telephone at the facility.

A license was given to the facility on 1/4/2023 and LPA reminded that for child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).
The child care center did not complete testing prior to the deadline.

The outdoor area of the facility was inspected and observed to be fenced in. The facility utilizes the elementary school playground, grass field, and blacktop area. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (tanbark) to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by large trees and building overhang.

Snack is provided by the facility and is stored, prepared, and served in a safe and healthful manner to the children. The menu is in writing and posted at least one week in advance, accessible to authorized representatives. LPA reminded that portion sizes shall be posted. Equipment necessary for the storage, preparation and service of food is well maintained, clean, and sanitized after each use.

Five (5) children’s files were reviewed during today’s inspection and all required documents were present including Acknowledgment of Receipt of Licensing Report (LIC9224).

Five staff files were reviewed and all required documents were present. The Site Director has current CPR/First-Aid that expires 7/2024 and Mandated Reporter Training that expires on 7/21/2024. LPA reminded that the Mandated Reporter Training must be renewed by all staff every 2 years.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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: 10/19/2023
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The Site Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

The Site Director understands that she shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded that there shall be at least one person with valid CPR and First-Aid certifications on site at all times or present during off site activities, such as field trips.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Exit interview conducted and report was reviewed with the Site Director, Stephanie Stellman.

As a result of today’s inspection, deficiencies were cited, see LIC809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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