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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700758
Report Date: 06/20/2023
Date Signed: 06/20/2023 11:43:54 AM

Document Has Been Signed on 06/20/2023 11:43 AM - 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KCE CHAMPIONS LLC @ MONTCLAIREFACILITY NUMBER:
435700758
ADMINISTRATOR:BJELEVAC, ADELAFACILITY TYPE:
840
ADDRESS:1160 SAINT JOSEPH AVENUETELEPHONE:
(669) 266-8477
CITY:LOS ALTOSSTATE: CAZIP CODE:
94024
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 0DATE:
06/20/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Cecelia GiuffridaTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Melanie Otsuji met with Interim Area Manager, Cecelia Giuffrida for an ANNOUNCED PRE-LICENSING INSPECTION. An application was submitted to request 90 school age children. The school age program is located on the Montclaire Elementary School campus which is part of Cupertino Union School District. The program is currently utilizing the two portables on the back side of the campus (Room 25 & Room 26). Hours of operation are from 7AM-8:30AM and 2:00-6:00PM, Monday through Friday. A health and safety inspection was conducted inside and outside.


INDOORS: EXEMPT
OUTDOORS: EXEMPT

This facility is exempt from square footage, fencing and bathroom requirements. Facility utilizes the grassy area, back playground and blacktop of the elementary school. Building overhang provides sufficient shade on the blacktop. Shade is provided by trees on the playground. Director is aware that there is to be no commingling of the children with the elementary school or any other programs on campus. Drinking water is available inside and outside by way of water dispenser and bottles brought from home. Facility provides PM snacks. Menus are posted. Facility has a functioning carbon monoxide detector, smoke detector and fire extinguisher. Facility has a sign in/out sheet that allows ample space for full legal signature and records time and date.

An approved Fire Clearance was received from Santa Clara County Fire Department for 90 school aged children with an approval date of 5/3/2023.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KCE CHAMPIONS LLC @ MONTCLAIRE
FACILITY NUMBER: 435700758
VISIT DATE: 06/20/2023
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This facility plans to provide Incidental Medical Services - IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

Applicant was 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 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.

A license for 90 school aged children will be issued once the following is received:



- Complete Director Packet for Diana Lozano-Valitera.

Exit interview conducted with Interim Area Manager, Cecelia Giuffrida.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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