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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416681
Report Date: 08/04/2021
Date Signed: 08/04/2021 01:52:57 PM

Document Has Been Signed on 08/04/2021 01:52 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 @ MURDOCK-PORTAL ELEMENTARYFACILITY NUMBER:
434416681
ADMINISTRATOR:JACQUELINE NAVARROFACILITY TYPE:
840
ADDRESS:1188 WUNDERLICH DRIVETELEPHONE:
(408) 665-9337
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 121TOTAL ENROLLED CHILDREN: 0CENSUS: 13DATE:
08/04/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Melissa JostedtTIME COMPLETED:
01:56 PM
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Licensing Program Analyst (LPA) Pete Hernandez conducted a scheduled Case Management - Licensee Initiated inspection with Licensee's Representatives, Area Manager Melissa Jostedt and Director Marcos Estrada.

Applicant KCE Champions LLC is requesting a change in rooms per the school District's request 1188 Wunderlich Drive San Jose, CA 95129. Per the School District request, the School-Age Center will be moving from the Wet Room/Library, Music/Science Room, Stage/Drama Room on a functioning school site TO class rooms numbers 25 and 26: Murdock-Portal Elementary School. A Fire Clearance was granted on 07/28/2021 by the San Jose Fire Department. The Fire extinguishers in the rooms were last serviced on 06/30/2021. LPA also observed that the facility has carbon and smoke detectors, and first aid kit.

The School-Age Center will operate Monday through Friday, serving children ages 4.9 to 12 years old. Facility maintains telephone service: (408) 665.9337.

Since this School-Age Center will be operating on a functioning school site, A signed letter dated 8/3/2021 was provided by the Principal providing permission to use the rooms 25 and 26. 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.

Rooms number 25 and 26 and the outdoor areas were inspected. Children at the Center will have access to the restrooms, sinks, and drinking water fountains on the school campus. There are restrooms located in each room occupied as well. The children will be using the Elementary School's Blacktop area for outdoor activities. LPA observed that the facility has a supply of play equipment for outdoor activities and outdoor activity space is enclosed with fencing and has shaded areas.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
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 3
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 @ MURDOCK-PORTAL ELEMENTARY
FACILITY NUMBER: 434416681
VISIT DATE: 08/04/2021
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Restrooms for boys and girls are separated and provide individual privacy outside the room however, the in classroom bathrooms are available to both males and females. Children will also be bringing their own water bottle and the Center has portable water dispenser to ensure that drinking water is available. Furniture and equipment for children to use were observed. There were tables and chairs for children to use. Weapons will not be stored on the premises and LPA did not observe any bodies of water on campus. The Center will not be providing transportation.

The Center will provide non-perishable snacks. Children will bring their own lunch when attending full day. LPA observed container used for storage of solid wastes has tight-fitting cover on. Detergents, cleaning compounds, sharps, medicines, and other items which could pose a danger if readily available to children were stored where they are inaccessible to children in care. Storage cabinets have locks. At the end of the day, facility will receive janitorial service provided by the school district.

LPA reminded facility of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person up to $3000.00 per person.

This facility plans to provide Incidental Medical Services – IMS. A Plan of Operation that includes IMS has been submitted to the Department. LPA had also provided to facility 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.

LPA reviewed with Melissa Jostedt the violations that would result in an immediate assessment of civil penalty in the amount of $500. Facility is encouraged to frequent the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Annual License fee, Adoption of new Laws, etc.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 @ MURDOCK-PORTAL ELEMENTARY
FACILITY NUMBER: 434416681
VISIT DATE: 08/04/2021
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LPA also discussed with Melissa Jostedt about the most current COVID-19 guidelines issued by the State (COVID-19 Updated Guidance: Child Care Programs and Providers) and the Santa Clara County Public Health Mandatory Directive for Programs Serving Children or Youth.

Exit Interview was conducted, where this report was reviewed with Applicant's Representative/Area Manager Melissa Jostedt.

This report will be subject to review by Management prior to approval.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC809 (FAS) - (06/04)
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