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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206844
Report Date: 07/06/2020
Date Signed: 07/29/2020 01:52:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:KCE CHAMPIONS LLC @ SANTA ROSAFACILITY NUMBER:
406206844
ADMINISTRATOR:SALLY IMMELFACILITY TYPE:
840
ADDRESS:8655 SANTA ROSATELEPHONE:
(805) 479-1226
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:100CENSUS: 7DATE:
07/06/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jennifer HokitTIME COMPLETED:
02:15 PM
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On 7/6/2020 at 1:30 pm Licensing Program Analysts (LPAs) Gigi Reyes and Francisca Velazquez conducted an unannounced case management tele-inspection regarding the incident which occurred on 6/15/2020. LPAs informed Director that due to COVID 19, a tele-inspection via Facetime will be conducted.

Director Jennifer Hokit reported that on 6/15/2020 Child # 1, Child # 2 and Child # 3 went to the bathroom when Child # 1 exposed Child # 1's self. On 7/6/2020,
LPAs conducted the physical plant tour, Director walked around the facility, based on the directions of the LPAs which allowed the LPAs to visually inspect the physical condition of the facility. There were 7 children and 2 staff present including the Director during the visit.

LPA interview with Director revealed that Director did not observe the actual incident because Director was standing by the bathroom door with the rest of the children who were lined up outside the bathroom. Child #2 and Child # 3 told Director the incident. LPA interview with Child #1 and Child #2 revealed that when children want to use the bathroom, children ask permission from teacher and proceed to the bathroom by themselves.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: KCE CHAMPIONS LLC @ SANTA ROSA
FACILITY NUMBER: 406206844
VISIT DATE: 07/06/2020
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Director denied children's claim that children go to the bathroom by themselves, director reaffirmed director was by the bathroom door when the incident happened. Director stated children referred to being by themselves when they are in the bathroom stall.

Director talked to Child # 1 and immediately informed the parent of Child # 1 about the incident. Parents of Child 2 and Child 3 were also informed of the incident. On the day of the incident there were 8 children and 2 staff present.

Further, director stated there was no prior and similar incident occurred involving Child # 1.

During today's case management visit, no deficiency was cited.

Notice of Site Visit was issued.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2020
LIC809 (FAS) - (06/04)
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