406206845-3-14-2022-17-CC-FPEA-CCHUPZ-20220314154622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406206845
Report Date: 03/14/2022
Date Signed: 03/14/2022 03:46:29 PM

Document Has Been Signed on 03/14/2022 03:46 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	KCE CHAMPIONS LLC @ SAN GABRIEL		FACILITY NUMBER:	406206845
ADMINISTRATOR:	TAMARA PAYNE-ALEX		FACILITY TYPE:	840
ADDRESS:	8500 SAN GABRIEL		TELEPHONE:	(805) 975-8429
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	50	CENSUS: 15	DATE:	03/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Deri-Kaye Ripel		TIME COMPLETED:	04:02 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 March 14, 2022 at 1:50 PM, Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced Annual/Random inspection. LPA met with facility Site Supervisor Deri-Kaye Ripel and advised her the purpose of the inspection. Site Supervisor provided LPA a tour of the facility inside and out. There were 15 children in care and two (2) staff supervising. Facility is located on a local elementary school grounds. The facility is using one (1) classroom for children in care. LPA observed licensing required documents posted prominently on the wall at the entrance of the facility. The center uses the school restroom for children in care. Children are escorted to the restroom when they request to use the restroom. Children hang their belongings on a hook when they enter the classroom. LPA observed age appropriate toys, activities, books, and furniture readily accessible for children to use. The center provides one stack for children during the afternoon while in care. Currently the facility is not providing Incidental Medical Services (IMS) to children in care. Children have the opportunity to use one of the school site's playground and grass area for outdoor recreation. Children have access to water inside and out. Some children bring their own water bottle from home. LPA observed the sign-in/sign-out sheet current. LPA reviewed a sampling of children and staff records. Children records were complete and current. Staff files were observed to be current and complete. LPA verified SB 792 Child Care Adult Immunization and Tuberculosis Requirements. Staff present were fully qualified with current Mandated Reporter and CPR/First-aid certificates. The last fire drill was completed on 12/07/2021. Facility is following current Covid-19 guidelines. LPA provided Site Supervisor with Carbon Monoxide resources. No deficiencies were cited during today's inspection. Continued on 809-C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

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 @ SAN GABRIEL	FACILITY NUMBER: 406206845
	VISIT DATE: 03/14/2022

NARRATIVE

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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

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Site Supervisor was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Site Supervisor.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

LIC809 (FAS) - (06/04)

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