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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421977
Report Date: 11/15/2023
Date Signed: 11/15/2023 01:15:22 PM

Document Has Been Signed on 11/15/2023 01:15 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KCE CHAMPIONS @ JAMES MADISON ELEMENTARY SCHOOLFACILITY NUMBER:
013421977
ADMINISTRATOR:YZABELLE ECHALASFACILITY TYPE:
840
ADDRESS:14751 JUNIPER STTELEPHONE:
(510) 246-1607
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY: 56TOTAL ENROLLED CHILDREN: 56CENSUS: 0DATE:
11/15/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Treniece FortsonTIME COMPLETED:
01:30 PM
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On 11/15/2023 at 10:05AM, Licensing Program Analyst (LPA) Jaleesa Jackson met with Treniece Fortson for an Unannounced Required Inspection for KCE Champions @ James Madison Elementary School. Present for the inspection were the Director, the interim site director, and 2 teachers who are all fingerprint cleared. The center is opened Monday through Friday from 7:00AM to 6PM. The center is located on the James Madison Elementary School campus. The Child Care Center was toured to conduct a Health and Safety Inspection.

The facility is located in a portable on the left side of James Madison Elementary School. The children are signed in and out with a binder located by the front door. There is one classroom at this center. The classroom has cubbies for personal items can be placed. The bathrooms are shared with the elementary school. The classroom has chairs and tables equipped for children to use. The isolation area is the multipurpose room. During today's inspection all hazardous materials and toxins are kept out of reach from children and are not accessible. There are two fully charged fire extinguishers located by both doors. There is one smoke detector, one carbon monoxide detector, a telephone and a fully stocked first aid kits in the classroom. The furniture around the classroom and outdoor area are all child proof and adequate for children to use. The learning materials are organized, and toys are kept in safety bins and cabinets for easy access for the children.

The facility provides snacks for the children. On minimum days the lunch is provided by the school or the children bring their own lunch from home. The menu is posted a month in advanced. The children bring their own water bottle from home and is refilled from water cooler in the classroom.

Continued on 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KCE CHAMPIONS @ JAMES MADISON ELEMENTARY SCHOOL
FACILITY NUMBER: 013421977
VISIT DATE: 11/15/2023
NARRATIVE
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LPA Jackson observed the outdoor area that has one play structure with slides. There is cushioning material around the play area to absorb falls. The outdoor play area is shared with the elementary school. There are no bodies of water on the premises. There are no firearms on premises.

LPA reviewed 5 children’s files and 4 staff files. LPA observed that 1 child's file was incomplete and only had the admission agreement. The file is missing the LIC700, LIC627, LIC995, and LIC613A. There is at least one staff at the facility with a valid CPR and First Aid. The facility conducts disaster drills at least every 6 months and the last drill was conducted 7/31/2023. All required forms are posted and visible for public view.

There were 2 deficiencies cited on today's visit. See 809-D for deficiencies.

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.



Facility representative 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.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.



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).
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
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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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KCE CHAMPIONS @ JAMES MADISON ELEMENTARY SCHOOL
FACILITY NUMBER: 013421977
VISIT DATE: 11/15/2023
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LPA referred licensee facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated 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) 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/.

Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representatives Treniece Fortson and Patricia Regalado.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2023 01:15 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 11/15/2023 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KCE CHAMPIONS @ JAMES MADISON ELEMENTARY SCHOOL
FACILITY NUMBER: 013421977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Director will send the following documents LIC700, LIC627, LIC995, and LIC613A of the child's file that is missing documents to LPA by email by POC date. POC date has been extended for fall break next week.
POC Due Date: 12/06/2023
Plan of Correction
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Director will send the following documents LIC700, LIC627, LIC995, and LIC613A of the child's file that is missing documents to LPA by email by POC date. POC date has been extended for fall break next week.
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Director will send the following documents LIC700, LIC627, LIC995, and LIC613A of the child's file that is missing documents to LPA by email by POC date. POC date has been extended for fall break next week.
POC Due Date: 12/06/2023
Plan of Correction
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Director will send the following documents LIC700, LIC627, LIC995, and LIC613A of the child's file that is missing documents to LPA by email by POC date. POC date has been extended for fall break next week.
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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023


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