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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 444417045
Report Date: 06/04/2024
Date Signed: 06/04/2024 01:25:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2024 and conducted by Evaluator Jessica Bongardt
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20240530112947
FACILITY NAME:KCE CHAMPIONS LLC @ BROOK KNOLL ELEMENTARYFACILITY NUMBER:
444417045
ADMINISTRATOR:SARAH HINKLEFACILITY TYPE:
840
ADDRESS:151 BROOK KNOLL DRIVETELEPHONE:
(408) 624-0534
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:121CENSUS: 0DATE:
06/04/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sarah HinkleTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff does not ensure electrical outlets are covered.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Jessica Bongardt met with DIrector, Sarah Hinkle for a initial 10-day unannounced complaint visit for the allegation above.

LPA toured the the inside of the facility and found that one of the electircal outlets did not have a cover on it which poses a potential threat to persons in care.

It had been reported to the department that the facility does not ensure that electrical outlets are covered.

Therefore this allegation will be SUBSTANTIATED, based on observation, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20240530112947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 @ BROOK KNOLL ELEMENTARY
FACILITY NUMBER: 444417045
VISIT DATE: 06/04/2024
NARRATIVE
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Exit Interview was conducted with Director, Sarah Hinkle. One deficiency was cited during during today's visit.

Appeal Rights were given.

Notice of Site Visit was given and MUST remain posted for 30 Days.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20240530112947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 @ BROOK KNOLL ELEMENTARY
FACILITY NUMBER: 444417045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
101238(b)(1)
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(b) All children shall be protected against hazards within the center through provision of the following:(1)Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
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Director will have a cover placed on the outlet by the plan of correction date and will send an photo to the department by the plan of correction date.
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Based on observation, there was not a cover on the electrical outlet near the entrance door that has the stairs. This poses a safety hazard to 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.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Jessica Bongardt
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3