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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343614708
Report Date: 04/23/2025
Date Signed: 04/23/2025 02:35:11 PM

Document Has Been Signed on 04/23/2025 02:35 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KCE CHAMPIONS LLC @ SUNRISE ELEMENTARYFACILITY NUMBER:
343614708
ADMINISTRATOR/
DIRECTOR:		FULTZ, SANDYFACILITY TYPE:
840
ADDRESS:11821 COBBLE BROOK DRIVETELEPHONE:
(916) 294-0061
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95742
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 14DATE:
04/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Stephany RooneyTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst Erwina Pascual-Golamco (LPA) met with Facility Representative Stephany Rooney (FR), for an unannounced annual inspection of this school age facility. LPA toured the facility, including all activity and classroom spaces, restrooms, and outdoor play area. FR was reminded never to exceed the conditions, limitations and capacity specified on the license. The facility is located on Sunrise Elementary School grounds in Portables 1 and 2. The school-age program is in Classroom #1, #3, and #4 from 6:30 AM to 6:00 PM. The facility operates Monday through Friday and is all year-around.

FR was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Classrooms observed are in good repair and free of hazards with heating and ventilation for safety and comfort. The facility has equipment and age-appropriate materials for children. Chemicals were kept inaccessible to children. Bathrooms were sanitary, sinks and toilets were in operating condition. The facility has a Playground Waiver on file for sharing the outdoor playground with Sunrise Elementary following a schedule. Uncontaminated drinking water was readily available to children both indoors and outdoors. The facility provides morning and afternoon snacks for the children. LPA observed a posted menu.

continued on LIC809-C...

Natalie DunawayTELEPHONE: (916) 584-3508
Erwina Pascual-GolamcoTELEPHONE: (916) 206-1524
DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KCE CHAMPIONS LLC @ SUNRISE ELEMENTARY
FACILITY NUMBER: 343614708
VISIT DATE: 04/23/2025
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There are no firearms or bodies of water on the premises and the facility has at least one functioning smoke and carbon monoxide detector. LPA observed all required licensing documentation was posted for parental review. LPA observed that parents are signing their children in and out of the center.

LPA reviewed with FR the LIC311A, Records to Be Maintained at The Facility, for child's records, personnel records, administrative records, and documents to be posted. Sample of children and staff files were reviewed. Children’s file had the required licensing documentation. LPA reviewed staff transcripts and observed staff caring for children were qualified. At least one staff had a current Pediatric CPR and First Aid certification. LPA observed a current fire drill log. There is First Aid equipment available.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES. Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.


LPA referred FR to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

FR was informed of the https://mychildcareplan.org/; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

continued on LIC809-C...

SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Erwina Pascual-GolamcoTELEPHONE: (916) 206-1524
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KCE CHAMPIONS LLC @ SUNRISE ELEMENTARY
FACILITY NUMBER: 343614708
VISIT DATE: 04/23/2025
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at

www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Deficiencies were cited during today's inspection. This report was reviewed with FR, and an exit interview was conducted. Appeal Rights and A Notice of Site Visit (NOS) was provided to FR, who will post it for a period of 30 days for parental review.

SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Erwina Pascual-GolamcoTELEPHONE: (916) 206-1524
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2025 02:35 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 04/23/2025 at 01:40 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KCE CHAMPIONS LLC @ SUNRISE ELEMENTARY
FACILITY NUMBER: 343614708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two staff files reviewed did not have a current Mandated Reporter certificate on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Facility Representative stated they will have staff complete the mandated reporter training and will email LPA by 4pm on POC due date that it has been completed and have placed certificates in their files.
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two staff files reviewed did not Health Screening report, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Facility Representative stated they will have staff get their Health Screening reports and will email LPA by 4pm on POC due date that it has been completed and have placed certificates in their files. If FR needs additional time, FR will email LPA for an extension.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Natalie Dunaway
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (916) 584-3508
Erwina Pascual-Golamco
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (916) 206-1524
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
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