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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444417045
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:23:56 PM

Document Has Been Signed on 02/01/2023 04:23 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 @ BROOK KNOLL ELEMENTARYFACILITY NUMBER:
444417045
ADMINISTRATOR:ANJELICA DEL TOROFACILITY TYPE:
840
ADDRESS:151 BROOK KNOLL DRIVETELEPHONE:
(408) 624-0534
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY: 121TOTAL ENROLLED CHILDREN: 90CENSUS: 56DATE:
02/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:19 PM
MET WITH:Sarah HinkleTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cortney Nelson and Jovani Dillon, met with Site Director, Sarah Hinkle, and explained purpose of today's visit.

LPA's reviewed staff files and observed that required documents are missing, such as physicians reports, proof of immunization record, tuberculosis test, Mandated Reporter training, and transcripts/proof of education. LPA's additionally noted that the Site Director is Sarah Hinkle and Area Manager, Anjelica Del Toro, failed to submit Site Director qualifications for review.

As a result of today's inspection, deficiencies have been cited, see 809-D.

Exit interview conducted and report was reviewed with the Site Director, Sarah Hinkle.

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: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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 2
Document Has Been Signed on 02/01/2023 04:23 PM - It Cannot Be Edited


Created By: Cortney Nelson On 02/01/2023 at 03:36 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 @ BROOK KNOLL ELEMENTARY
FACILITY NUMBER: 444417045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
101212(b)(1)(A)

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101212 Reporting Requirements (b) The name of the child care director.. shall be reported to the department within 10 days.. (1) ...in addition to his/her name, the report shall include the following: (A) Verification of the completion of course work required in Section 101215.1(h)...

This requirement was not met as evidenced by:
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Area Manager will submit proof of Site Director qualifications and be sure to include education requirements, proof of experience from previous employers, MMR vaccination by 2/3/2023
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Area Manager indicated Sarah Hinkle on LIC200A, however did not submit qualifications for review which poses a potential threat to the health, safety, and personal rights of children in care.
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All required qualifications paperwork should be submitted for review.
Type B
02/03/2023
Section Cited
CCR101217(a)

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101217 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 was not met as evidenced by:
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Area Manager, Anjelica Del Toro, will submit proof of education/transcripts, Mandated Reporter training, immunizations (MMR, Tdap, flu), and required experience for review to determine qualifications of staff.
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The licensee failed to maintain personnel records as many required documents were missing which poses a potential threat to the health, safety, and personal rights of children in care.
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Staff are additionally missing proof of physicians report and negative TB test, which should also be submitted. All documents should be submitted by 2/3/2023 for all staff present during 2022-2023 school year.
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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2