406206844-9-2-2021-17-CC-MKST-C6GTR3-20210902145652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406206844
Report Date: 09/02/2021
Date Signed: 09/02/2021 02:56:59 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 ROSA		FACILITY NUMBER:	406206844
ADMINISTRATOR:	TAMARA PAYNE-ALEX		FACILITY TYPE:	840
ADDRESS:	8655 SANTA ROSA		TELEPHONE:	(805) 479-1226
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	100	CENSUS: 11	DATE:	09/02/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Bridget Miles		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/2/2021 at 1:35pm, Licensing Program Analyst (LPA) Melissa Stewart arrived at school age program classroom #1702 where S1 was supervising 10 kindergarteners who were engaged in various age appropriate activities indoors. The purpose and nature of the Required- 1 year inspection was explained. The school age program operates in classroom # 1702 and #1701, Monday - Friday 12:10pm-6pm. All required forms, including monthly menu, are posted on the wall adjacent to the front entrance. The number of children signed in by S1 corresponded with the number of children present. AT 1:42pm, S1 left the classroom with all 10 children to pick up 2 (two) additional children who were just getting out of class. The classroom was observed to be clean, organized and free of toxins. There are child sized furnishings and various activity areas containing books, puzzles, manipulatives, blocks, arts and crafts and dramatic play materials. Drinking water is available both inside via water cooler and disposable cups. S2 arrived at 1:50pm. The first aid kit is located in a fanny pack on the water cooler cart which accompanies the children during outside play time. Medications are stored in a locked box in a metal cabinet. Detergents, cleaning compounds and other items which could pose a danger to children are stored in a wall mounted cabinet with a padlock. The carbon monoxide detector was tested and found to be operational. Children use the boys and girls restrooms located in the building directly across from their classroom. S2 reported that emergency drills are conducted monthly, but a drill has not been conducted since school started on 9/11/2021. Continued on 809-C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K Stewart	TELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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: 09/02/2021

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. S2 reported that that there are no children currently enrolled who require IMS. 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: www.ada.gov/childqanda.htm

S3 and S4 arrived at approximately 2pm. A sample of children's files and staff files were reviewed at 2:05pm. S1 has met immunization requirements per SB 792 and has current Pediatric CPR and First Aid certification expiring in March 2023. Staff are in process of renewing their AB 1207 Mandated Reporter Training. S1 is a fully qualified director and completed Universal Precautions Training on 3/9/2021. S1 left for a lunch break prior to the completion of this report.

LPA provided the “Effects of Lead Exposure” brochure to be distributed to all families at time of enrollment. LPA advised that Community Care Licensing Division (CCLD) Provider Information Notices (PINs), Title 22, Division 12 regulations and California Department of Public Health COVID-19 guidelines for child care programs can be accessed on-line at www.cdss.ca.gov. COVID19 Information for San Luis Obispo County can be found at https://www.emergencyslo.org/en/covid19.aspx.

In the areas evaluated, no deficiencies cited today. A copy of this report and appeal rights were discussed and left with Facility Representative, Bridget Miles, whose signature on this form confirm receipt of these documents.

LPA provided a Notice of Site Visit (LIC 9213) to be posted. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100.00 CIVIL PENALTY

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K Stewart	TELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC809 (FAS) - (06/04)

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