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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444417045
Report Date: 05/14/2024
Date Signed: 05/14/2024 04:15:02 PM

Document Has Been Signed on 05/14/2024 04:15 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 @ BROOK KNOLL ELEMENTARYFACILITY NUMBER:
444417045
ADMINISTRATOR/
DIRECTOR:		SARAH HINKLEFACILITY TYPE:
840
ADDRESS:151 BROOK KNOLL DRIVETELEPHONE:
(408) 624-0534
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY: 121TOTAL ENROLLED CHILDREN: 117CENSUS: 64DATE:
05/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Sarah HinkleTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst(LPA) Jessica Bongardt met with Director Sarah Hinkle for a Case Management because of an incident that occurred on 04/30/2024. The incident that occurred was two children were found between classroom 10 and the bathroom grabbing each other in their private area and exposing themselves to each other.

Staff and child interviews were completed, child and staff records were reviewed.

LPA found due to lack of supervision, that is why this incident was able to occur and pose a potential safety risk to children in care.

Three deficiencies was sited during today's visit, please see LIC 809-D's.

Exit Interview was completed with Director, Sarah Hinkle.

Appeal Rights were given.

Notice of site visit was issued during today's visit, and must be posted for 30 days.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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 3
Document Has Been Signed on 05/14/2024 04:15 PM - It Cannot Be Edited


Created By: Jessica Bongardt On 05/14/2024 at 02:53 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: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
101229(a)(1)

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(a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1)No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation. This requirement was not met as evidenced by:
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Training of staff is to be completed and a outline of the training and a sign in sheet will be submitted to the department before the plan of correction date.
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Staff was not watching the children as it was a maintenance worker from the school district who saw the children and reported it to the Director.
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Type B
05/17/2024
Section Cited
CCR101221(a)(b)

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(a) A separate, complete and current record for each child is maintained in the child care center.(b)Each record shall contain information including, but not limited to, the following:(1)Name of child.
(2) Birthdate.(3)Sex.(4)Date of Admission.(5)Name, address
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Director will have C2's parents fill out all necessary enrollment paperwork and scan copies to the department by the plan of correction date.
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 This requirement was not met as evidenced by:

C2's file had no admission paperwork in it.
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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:Belinda Devall
LICENSING EVALUATOR NAME:Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2024 04:15 PM - It Cannot Be Edited


Created By: Jessica Bongardt On 05/14/2024 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: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
101218.1(b)

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(b) At the time of acceptance of each child in care, the licensee shall inform each child's parent or authorized representative of his/her rights that include, but are not limited to, the following: (1)To enter and inspect the child care center in accordance with Health and Safety Code Section 1596.857. (2)To file a complaint against the licensee with the local licensing office in accordance with Health and Safety Code Section 1596.853.(3) To review the child care center’s public file kept by the local licensing office in accordance with Health and Safety Code Section 1596.859.(4)To review at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years in accordance with Health and Safety Code Section 1596.859.(5) To complain to the local licensing office and inspect the child care center without discrimination or retaliation in accordance with Health and Safety Code Section 1596.857. (6)To request in writing that a parent not be allowed to visit a child or take a child from the child care center provided the custodial parent has shown a certified copy of a court order pursuant to Health and Safety Code Section 1596.857.(7) To receive from the licensee upon request the name, address and telephone number of the local licensing office in accordance with Health and Safety Code Section 1596.874.
(8) To be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.
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Director will have parents sign the Parents Rights form and scan the signed document to the department by the plan of correction date.
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 This requirement was not met as evidenced by:

There was not a signed parents rights in C2's file.

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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:Belinda Devall
LICENSING EVALUATOR NAME:Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
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