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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623554
Report Date: 09/09/2020
Date Signed: 09/09/2020 12:14:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:KCE CHAMPIONS LLC @ JOHN ADAMS LINCOLN CAMPUSFACILITY NUMBER:
313623554
ADMINISTRATOR:KIRSCH, ANGELAFACILITY TYPE:
840
ADDRESS:1797 BELLA BREEZE DRIVETELEPHONE:
(916) 479-4977
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:121CENSUS: 0DATE:
09/09/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shelly DuncanTIME COMPLETED:
11:00 AM
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Application Specialist (AS) Seychelle De Luca and Licensing Program Analyst (LPA) Amanda Blesi met with Licensee Representative Shelly Duncan for the purpose of an announced prelicensing tele-inspection (due to COVID-19). Licensee Representative requests a school-age license to serve 121 school-age children enrolled in kindergarten and above. The program will operate Monday through Friday from 6:30 AM to 6:00 PM. Licensee Representative submitted the elementary school’s fire clearance.

Licensee Representative acknowledges that the following documents must be posted at all times: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, menus, and daily schedule. Licensee Representative requested a waiver for all employee clearances to be associated to Champions @ John Adams #313621215. AS granted the waiver and Licensee Representative understands the waiver must be posted at all times and the conditions of the waiver must be met. AS and LPA discussed the forms that must be in each child's and each staff member's file. The facility will be providing morning and afternoon snack and children will bring their own lunches.

INDOOR ACTIVITY SPACE:
Licensee Representative requests to use classroom 212 (main room), 214, cafeteria, gym, and lecture hall. AS and LPA observed a sufficient amount of equipment and cubbies. There is a first aid kit in the classroom. Medications will be stored in the classroom in a locked box. AS and LPA observed cleaning disinfectants are appropriately stored and inaccessible to children. Licensee Representative stated there are no poisons or firearms on the premises. AS and LPA observed water cooler and paper cups in the classrooms and automatic water bottle stations in the hallway. Licensee Representative stated the carbon monoxide detector is hardwired into the alarm system. AS and LPA observed a paper sign-in/sign-out system.

Report continues on 809-C.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: (916) 217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: KCE CHAMPIONS LLC @ JOHN ADAMS LINCOLN CAMPUS
FACILITY NUMBER: 313623554
VISIT DATE: 09/09/2020
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Licensee Representative will send AS a signed letter from Principal of John Adams School - Lincoln. Licensee Representative stated the letter will state the activity space is of sufficient size to accommodate Licensee Representative’s requested capacity of 121 school-age children. Per Health and Safety Code 1596.806, the facility is exempt from square footage requirement; therefore, AS and LPA did not take measurements. The children will use the school’s restrooms, and there is a separate private restroom for the staff. Children who become ill during the day will be isolated in the front office and will use the staff restroom, if necessary.

OUTDOOR ACTIVITY SPACE:
There is one outdoor area on the property. AS and LPA observed a sufficient amount of equipment and toys. Licensee Representative stated the climbing structure is anchored into the ground. There are no bodies of water on the premises. There are shaded areas supplied by trees.

The facility's Plan of Operation is located in the Administrative file. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

AS and LPA discussed the following: supervision; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. AS and LPA discussed with Licensee Representative any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

Report continues on 809-C.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: (916) 217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: KCE CHAMPIONS LLC @ JOHN ADAMS LINCOLN CAMPUS
FACILITY NUMBER: 313623554
VISIT DATE: 09/09/2020
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This facility evaluation report was reviewed and discussed with Licensee Representative. Licensee Representative was encouraged to the visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers.

AS emailed a copy of the 809 to Licensee Representative. Licensee Representative understands she must read the report and send AS an email stating she received, read, and understands today’s report. AS also provided LIC311A, Effects of Lead Exposure brochure, and Healthy Schools Act survey.

Director is enrolled in a Lead Prevention course that is scheduled for September 19, 2020.

CONDITIONS REQUIRING CORRECTION PRIOR TO ISSUING A LICENSE:


1. Submit remaining paperwork: list of furniture, lease, LIC 610, LIC 500, and CA Authorization letter.

2. Submit Principal's letter and safety label for the climbing structure.

3. Submit Director's completed Lead Prevention certificate.

4. Proof of 61 more cubbies/hooks, installation of shade structure, and completion of fence.

5. A final review of the file by Licensing Program Manager (LPM) Keven Peters.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: (916) 217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020
LIC809 (FAS) - (06/04)
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