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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444416988
Report Date: 12/18/2024
Date Signed: 12/18/2024 04:02:31 PM

Document Has Been Signed on 12/18/2024 04:02 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KCE CHAMPIONS LLC @ BONNY DOONFACILITY NUMBER:
444416988
ADMINISTRATOR/
DIRECTOR:		JACKSON SHERIDANFACILITY TYPE:
840
ADDRESS:1492 PINE FLAT ROADTELEPHONE:
(408) 624-0533
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 15DATE:
12/18/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Jackson SheridanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On December 18, 2024 at 1:45 PM., Licensing Program Analyst (LPA) Elimika Woods conducted an unannounced 3 Year Required Inspection and met with the facility representative Jackson Sheridan. LPA disclosed the purpose of the inspection and was granted entry into the facility by the facility representative. There were 15 school age children present during this inspection and one (1) additional staff member. The facility consists of one classroom. The facility was toured inside and out for a health and safety inspection. The hours of operation are 2:30 PM- 5:30 PM, M-F and on early release days the schedule is 12:30 PM to 5:30 PM.

LPA checked the facility RECORDS and they show all individuals subject to criminal record review have a clearance or exemption and have been associated to the facility. LPA conducted a census of the children and the census matches the 15 names signed in on the sign in sheet. LPA reviewed three (3) children's files and one (1) staff file around 2:15 PM. All children files contains Personal Rights, Medical Consent forms, and Identification & Emergency Information. At least one opening/ closing staff member has a current CPR & First Aid Certificate.

The one (1) classroom was inspected around 1:50 PM, and teacher child ratio was observed. There are adequate play and learning materials available. The floors surfaces are well maintained, safe and clean, and the furniture is the correct size for school age children. The classrooms equipment is in good repair and the room temperature is adequate for children in care. There is proper individual storage space for each child. The isolation area for sick children is next to the director's desk, away from other children in care.

The center has a working telephone, first aid kits, and a fully charged 2A10BC fire extinguishers, which meets standards established by the State Fire Marshal hanging on the wall by the front door. Disaster drills are being conducted at least once every 6 months and the last one conducted was on 09/11/2024. All required documents are posted in a public accessible area.

See 809-C.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KCE CHAMPIONS LLC @ BONNY DOON
FACILITY NUMBER: 444416988
VISIT DATE: 12/18/2024
NARRATIVE
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This facility provides snacks for children in care and there are weekly menus posted at the facility. LPA observed an area where they have a mini refrigerator this area is clean and free of evidence of rodents. LPA reminded the facility representative that all persons engaged in food preparation and service shall observe personal hygiene and food service sanitation practices to protect food from contamination. All storage containers for solid waste have tight fitting covers that are in good repair.

The outdoor area has a play structure with a slide that has cushioning to absorb falls and a swing set that's anchored to the ground. There are trees that provides shade to children while at play. The play equipment is age appropriate and in good repair. The outdoor play area is the blacktop area and upper play area and they are free of defects and dangerous condition.



LPA checked the staff bathroom around 3:00 PM, and was told by the representative it was separate from the children’s bathroom. The children's bathrooms are both located to the right of the classroom. All of the sinks, toilets, and faucets are in safe and sanitary operating condition during todays inspection.

California Law requires Child Care Centers licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. The facility representative was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, a Plan for Providing 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: https://www.ada.gov/resources/child-care-centers/



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.

See 809-C

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KCE CHAMPIONS LLC @ BONNY DOON
FACILITY NUMBER: 444416988
VISIT DATE: 12/18/2024
NARRATIVE
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The 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.

The 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.

See 809-D for deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative Jackson Sheridan.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Elimika Woods
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/18/2024 04:02 PM - It Cannot Be Edited


Created By: Elimika Woods On 12/18/2024 at 03:24 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 @ BONNY DOON
FACILITY NUMBER: 444416988

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which the center did not have a carbon monoxide and smoke detector at their facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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The facility representative will purchase a smoke & carbon monoxide detector and contact LPA by phone for an appointment to clear the deficiency by 1/02/2024.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which the staff did not have mandated reporter certificates in their files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2024
Plan of Correction
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The facility representative will forward a copy of completed Mandated Reporter Training certificate for the staff members to CCLD by 12/02/2024 by fax, text, or email.
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:Chandra Charles
LICENSING EVALUATOR NAME:Elimika Woods
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/18/2024 04:02 PM - It Cannot Be Edited


Created By: Elimika Woods On 12/18/2024 at 03:24 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 @ BONNY DOON
FACILITY NUMBER: 444416988

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which the teachers aide did not have her staff file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2024
Plan of Correction
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The facility representative will provide the LPA with the teacher's aide file by 12/02/24 by email.
Type B
Section Cited
CCR
101217(d)
Personnel Records
(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which the staff file was not made readily available to the LPA which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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The facility representative will provide the LPA with the teacher's aide file by 12/02/24 by email.
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:Chandra Charles
LICENSING EVALUATOR NAME:Elimika Woods
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


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