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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416682
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:51:56 PM

Document Has Been Signed on 05/04/2023 01:51 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KCE CHAMPIONS LLC @ BLUE HILLS ELEMENTARYFACILITY NUMBER:
434416682
ADMINISTRATOR:ISAAK RAMIREZFACILITY TYPE:
840
ADDRESS:12300 DE SANKA AVENUETELEPHONE:
(925) 457-7138
CITY:SARATOGASTATE: CAZIP CODE:
95070
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 0DATE:
05/04/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Isaak RamirezTIME COMPLETED:
02:25 PM
NARRATIVE
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On 03/08/2023, Licensing Program Analyst (LPA) Pete Hernandez, met with Director, Isaak Ramirez, for a case management visit in regards to the lead testing results submitted by the facility and explained the reason for the visit to them. Present were 1 staff with 0 children in care.

Facility submitted that there is an exceedance of about 10 (ppb) sample (B) room 28 from the sink faucet Director stated that all the above have been disabled and repairs are expected in two weeks once ordered parts are received. Retesting will be scheduled once repairs are completed. They are expected to be completed before end of school year on June 13, 2023. The facility uses water for the staff and children from other faucets that have passed lead safety testing of 5.5 (ppb) or less.

Type B deficiency was cited during today's visit. Director was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made. Exit interview conducted and report was reviewed with the Director, Isaak Ramirez,

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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 05/04/2023 01:51 PM - It Cannot Be Edited


Created By: Pietro Hernandez On 05/04/2023 at 01:40 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KCE CHAMPIONS LLC @ BLUE HILLS ELEMENTARY
FACILITY NUMBER: 434416682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2023
Section Cited

101700.3(b)(1)

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101700.3(b)(1)
Testing results with fractional ppb readings of 0.5 ppb or greater shall be rounded up to the nearest whole number, before comparing to the Action Level. A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.
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By the POC date: Facility will provide proof of repairs and retest results by 6/02/2023. Identified fixtures are not to be used until cleared for use after retesting.
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Facility submitted that there is an exceedance of about 10 (ppb) sample (B) room 28 from the sink faucet.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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