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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444417046
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:16:10 PM

Document Has Been Signed on 01/16/2024 02:16 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 @ VINE HILL ELEMENTARYFACILITY NUMBER:
444417046
ADMINISTRATOR:STEPHANIE STELLMANFACILITY TYPE:
840
ADDRESS:151 VINE HILL SCHOOL ROADTELEPHONE:
(408) 624-0534
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 23DATE:
01/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sarah HinkleTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cortney Nelson, met with Site Director, Sarah Hinkle, to follow-up on incident reported to the Department on 1/8/2024. Upon arrival, LPA was admitted into the facility by staff member, Jesse, and explained purpose of today's visit. Jesse advised LPA that Site Director, Stephanie Stellman, is on vacation and will not be present at the facility today.

On 1/8/2024, the facility self-reported to the Department that C1 was left outside unattended when the child's parent came to pick-up. C1 was left outside on 12/21/2023 during a winter camp held at the Vine Hill campus. Children from KCE Brook Knoll were also in attendance during the camp. The parent of C1 notified Site Director, Sarah Hinkle, on 1/3/2024 that C1 was observed outside and unattended during pick-up on 12/21/23. There was a delay in sharing that C1 was left outside as no Site Directors were present when C1 was picked up that day. LPA reminded that a fully qualified teacher shall act as a substitute while a Site Director is not present and shall be aware of the responsibilities while acting as director.

The facility has indicated that they will be conducting a staff meeting to review child supervision best practices and transitions on 1/10/2024 for Brook Knoll and 1/18/2024 for Vine Hill. A review of supervision policies and proper headcount procedures will additionally be reviewed.

LPA reminded of the reporting requirements that events shall be reported to the Department within the next working day and during its normal business hours. LPA additionally reminded that all staff present shall have their fingerprint clearances transferred to KCE Vine Hill or any other facility that may combine for camps.

As a result of today's inspection, deficiencies were cited, see LIC809-D.

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

A NOTICE OF SITE VISIT WAS GIVEN AND SHALL BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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 4
Document Has Been Signed on 01/16/2024 02:16 PM - It Cannot Be Edited


Created By: Cortney Nelson On 01/16/2024 at 01:27 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 @ VINE HILL ELEMENTARY
FACILITY NUMBER: 444417046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2024
Section Cited
CCR
101229(a)(1)

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101229 Reponsibility for Providing Care and Supervision (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.
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The facility states that they will be hosting meetings with their staff to review child supervision records, supervision policies, and proper head count procedures on 1/18/24 for Vine Hill and 1/10/24 for Brook Knoll.

*$500 civil penalty assessed
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This requirement was not met as evidenced by:

On 12/21/2023 during a winter break camp held at the facility, a child was left outside on the playground without supervision, which poses an immediate 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: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2024 02:16 PM - It Cannot Be Edited


Created By: Cortney Nelson On 01/16/2024 at 01:41 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 @ VINE HILL ELEMENTARY
FACILITY NUMBER: 444417046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2024
Section Cited
CCR
101212(d)(1)(C)

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101212 Reporting Requirements (d) Upon the occurrence... a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.. a written report.. shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include the following: (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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The UIR has been submitted to the Department on 1/8/2024. LPA reminded of the initial reporting requirement within 24 hours or one working day.
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This requirement was not met as evidenced by:

The facility was notified about a child being left outside unattended on 1/3/2024 and the initial report to the Department was made on 1/8/2024, which poses a potential risk to the health, safety, and personal rights of children in care.
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Type B
01/19/2024
Section Cited
CCR101170(e)(2)

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101170 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...

This requirement was not met as evidenced by:
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The facility shall transfer the fingerprint clearances for any staff that may work at Brook Knoll or Vine Hill and confirm their prints have been transferred prior to initial presence in the facility. All transfers shall be completed by 1/19/2024.
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During winter camp hosted at Vine Hill, staff from Brook Knoll were assisting without fingerprint clearance transfer between the facilities, 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: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/16/2024 02:16 PM - It Cannot Be Edited


Created By: Cortney Nelson On 01/16/2024 at 01:50 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 @ VINE HILL ELEMENTARY
FACILITY NUMBER: 444417046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
101215.1(f)

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101215.1 Child Care Center Directors Qualifications and Duties (f) When the child care center director is absent from the center, arrangements shall be made for a fully qualified teacher... to act as substitute. This substitute child care center director shall be aware of center operations, including total enrollment; shall be trained in program operation; and shall be designated as an authorized person to correct operational deficiencies that constitute immediate threats to children's health and safety.

This requirement was not met as evidenced by:
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The facility to designate a fully qualified staff member when a Site Director is not present. A copy of staff that shall act as director during their absense shall be submitted to the Department on 1/19/2024.
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When the Site Director left the facility at 4:00PM on the day of the incident, she did not designate a fully qualified teacher to act as a substitute director, 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: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
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