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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444417045
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:12:38 PM

Document Has Been Signed on 04/11/2023 04:12 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: 108CENSUS: 21DATE:
04/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sarah HinkleTIME COMPLETED:
04:23 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cortney Nelson, met with Site Director, Sarah Hinkle, and explained purpose of visit. LPA was admitted into the facility by the Site Director and toured inside and outside during today's inspection.

LPA observed sign-in sheets are not completed by staff for children upon arrival, personnel files are missing required documents, and staff fingerprint clearances have not been obtained prior to initial presence in the facility. LPA advised that any staff members without fingerprint clearances may not be present at the facility until clearances have been obtained.

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

LPA informed Site Director, Sarah Hinkle, that this report dated 4/11/2023 documents one Type A citation, which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed the Site Director to provide a copy of this licensing report dated (4/11/2023) that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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

A NOTICE OF SITE VISIT WAS GIVEN AND MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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 5
Document Has Been Signed on 04/11/2023 04:12 PM - It Cannot Be Edited


Created By: Cortney Nelson On 04/11/2023 at 01:07 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2023
Section Cited
CCR
101216(g)(1)

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101216 Personnel Requirements (g) All personnel... shall be in good health.. and mentally capable of performing assigned tasks. (1) ...good physical health shall be verified by a health screening, including a test for tuberculosis, performed by... a physician not more than one year prior to or seven days after employment.
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The Licensee will submit copies of completed physicians report or appointment confirmation for six staff missing physicians reports. The screening must include test for tuberculosis.
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This requirement was not met as evidenced by:

The Licensee did not obtain physicians report for six out of eleven staff files reviewed, which poses a potential risk to the health, safety, and personal rights of children in care.
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Type B
04/18/2023
Section Cited
HSC1596.7995(c)

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(c) The day care center shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the day care center.
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The Licensee will submit proof of required immunizations (Tdap, MMR, flu) to the Department by 4/18/2023. A declination of the flu vaccine may be signed and submitted.
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This requirement was not met as evidenced by:

The Licensee did not maintain proof of required immunization for three out of eleven staff files reviewed, which poses a potential risk to the health, safety, and personal rights of children in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2023 04:12 PM - It Cannot Be Edited


Created By: Cortney Nelson On 04/11/2023 at 01:19 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
HSC
1596.8662(b)(1)

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...a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training... and shall complete renewal mandated reporter training every two years..

This requirement was not met as evidenced by:
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The Licensee will submit proof of completion of required mandated reporter training (Child Care Providers AB1207) for six staff and submit to the Department by 4/14/2023.
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The Licensee did not have proof of completion of required mandated reporter training for six out of eleven staff files reviewed which poses a potential risk to the health, safety, and personal rights of children in care.
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Type B
04/18/2023
Section Cited
HSC1596.841

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Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.
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The Licensee will submit a fully completed facility roster to the Department by 4/18/2023.
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This requirement was not met as evidenced by:

The Licensee did not have a current facility roster for children who are provided care, which poses a potential risk to the health, safety, and personal rights of children in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2023 04:12 PM - It Cannot Be Edited


Created By: Cortney Nelson On 04/11/2023 at 01:35 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
101229.1(b)

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101229.1 Sign In and Out (b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

This requirement was not met as evidenced by:
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The Licensee will submit plan for ensuring that children arriving after school are signed in upon arrival. The plan will outline who will sign children in and how ratio will be maintained during the staggered arrival time.
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The Licensee did not sign children into the facility upon arrival after school, which poses a potential risk to the health, safety, and personal rights of children in care.
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Letter outlining how sign-in/out will be completed should be submitted to the Department by 4/14/2023.

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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2023 04:12 PM - It Cannot Be Edited


Created By: Cortney Nelson On 04/11/2023 at 01:42 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/12/2023
Section Cited
CCR
1596.871(c)(1)(A)

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Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification... from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement was not met as evidenced by:
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The Licensee will transfer/complete fingerprint clearances for those not associated to the facility. Any employees who do not have clearances should not be present in the facility until they have been obtained.
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The Licensee did not complete criminal record clearances/transfer prior to initial presence in the facility for seven staff members which poses an immediate risk to the health, safety, and personal rights of children in care.
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Civil penalty assessed.

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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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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