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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444416988
Report Date: 07/30/2021
Date Signed: 12/27/2022 03:40:28 PM

Document Has Been Signed on 12/27/2022 03:40 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 @ BONNY DOONFACILITY NUMBER:
444416988
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:1492 PINE FLAT ROADTELEPHONE:
4083481610
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 0DATE:
07/30/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tamara Payne-Alex TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Stephanie Collins conducted an announced Pre-Licensing Inspection. LPA met with the Director Tamara Payne -Alex . LPA explained the nature of the inspection; KCE Champions LLC is applying for a license to operate a School-Age Center Program to service 30 School Age Children at the address shown above. The school age program is located on the campus of an active elementary school (Bonny Doon Elementary School) The School Age Program is located in the After-School Program Room and Library Room on the school campus. The fire clearance was granted on 07/08/2021 by the Pajaro Valley Fire Protection. The school-age center will operate Monday, Tuesday, Thursday and through Friday: 2:30 PM to 5:30 PM and Wednesdays 12:45 PM-5:30 PM. serving children from 5-12 years old. Facility maintains telephone service (408 )348-1610.

Since this School-Age Program will be operating on a functioning school site, the Program is exempt from requirement for square-footage of 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. ( Principal's letter on file)

Furniture and equipment for school age children to use were observed. There were tables and chairs to accommodate the maximum capacity of children requested. A fully charged fire extinguisher was observed along with a carbon monoxide detector in the school age classroom. LPA observed that there is are dedicated restroom assigned to the School Age Program; There are two restroom with a total 4 toilet and 2 sink. The School- Age children will not be sharing the playground. The outdoor activity space is enclosed with fencing. Shade is provided by trees.

Weapons will not be stored on the premises. The program will not be providing transportation. Facility will provide an afternoon snack. LPA observed containers used for solid wastes has tight-fitting covers. 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 areas have locks.






SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KCE CHAMPIONS LLC @ BONNY DOON
FACILITY NUMBER: 444416988
VISIT DATE: 07/30/2021
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The After-School Program Room, Library , and the outdoor areas were inspected. Children in the Program will have access to the restrooms, sinks, and drinking water on the school campus. For outdoor activities, the children will be using the elementary schools Blacktop/Basketball Courts area, field, and play structures . The outdoor activity space is enclosed with fencing. Areas under high climbing equipment has material that absorbs falls. Shade is provided by tress.

The children will have access to a water cooler, water pitchers as well as encouraged to bring their own water bottle to ensure that drinking water is available. Furniture and equipment for children to use were observed. There were tables and chairs to accommodate the maximum capacity of children requested. The Program will not be providing transportation.




Facility will provide PM snacks. 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 areas have locks. At the end of the day, facility will receive janitorial service provided by the school district.


SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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 @ BONNY DOON
FACILITY NUMBER: 444416988
VISIT DATE: 07/30/2021
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LPA informed the facility that as of today, 07/30/21, Director has received Criminal Background and Child Abuse Index Clearance.

LPA reminded the 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 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)/ (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 Director Tamara Payne-Alex the violations that would result in an immediate assessment of civil penalty in the amount of $500.

Facility is encouraged to visit 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.

Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility

Exit Interview was conducted, where this report was reviewed with Tamara Payne-Alex

Applicant representative Tamara Payne- Alex- was informed that once Licensing Office receives all required documents the Application file will be submitted to Licensing Management for review and final approval.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Stephanie Collins
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC809 (FAS) - (06/04)
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