406206845-5-3-2023-17-CC-EBAY-CRGSTS-20230503141000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406206845
Report Date: 04/26/2023
Date Signed: 05/03/2023 02:11:02 PM

Document Has Been Signed on 05/03/2023 02:11 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: 26	DATE:	04/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:31 PM
MET WITH:	Deri Kaye		TIME COMPLETED:	05:00 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 4/26/23, at 3:31 PM, Licensing Program Analysts (LPAs) Elvin Baddley and Dixie Wright conducted an unannounced One Year Required inspection the abovementioned Child Care Center (CCC). LPAs met with Deri Kaye, Site Supervisor of the CCC and explained the purpose of the inspection. LPAs, in the company of Site Supervisor, toured the interior and exterior of the CCC. The CCC operates out of a module classroom (Room 1007) on the grounds of San Gabriel Elementary School. The CCC's hours of operation are 7:00 AM to 6:00 PM, Monday - Friday. LPAs observed 26 children in the CCC along with four teachers (cleared and associated) providing care and supervision. LPAs observed a snack menu posted along with required notices and documents on the classroom's walls. LPAs reviewed children's In/Out forms and found the arrival times of children as well as the departure times. The signature of authorized representatives are also noted on the forms. The classroom of the CCC is organized and clean. The classroom has age appropriate furnishings for children in care. The classroom has an operable refrigerator which contains food items consumed by the CCC's children. Food items in the CCC's refrigerator are labeled. The CCC provides afternoon snacks. There is available drinking water for children both outside and inside and the CCC and water sources at the CCC have been tested for lead containments. LPAs observed a carbon monoxide detector on the wall of the classroom which was tested at 3:45 PM and found to be operable. Disinfectants, cleaning solutions, sharps and medications are stored in inaccessible locations in the CCC. The restrooms of the CCC are located on school grounds. LPAs observed the restrooms to be in sanitary operating condition. Staff members ensure children are escorted to the restrooms and the restrooms are only being used by CCC children at times of use. The outdoor playground area is enclosed by chain linked and the footing in the area is varied. Play (CONT. LIC 809-C)

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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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Document Has Been Signed on 05/03/2023 02:11 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2023

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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above as Site Supervisor (expiration 11/20/21) and Administrator's(expirations 1/20/22) certifications were not current which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Complete Mandated Reported Training and submit certification to CCLD by 5/10/23 (elvin.baddley@dss.ca.gov)

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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: 04/26/2023

NARRATIVE

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ground equipment in the area is also varied. The shade in the area is created by a gazebo, trees and building overhangs.

Staff and children records were reviewed. The children’s records were complete and found to contain emergency contact information as well admission agreements . Staff records were reviewed. At 4:00 PM, Mandated Reporter certifications for Administrator and Site Supervisor were observed to be expired. .LPAs informed Site Supervisor of the need to ensure Mandated Report training certifications are current and renewed every two years.

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

Facility representative 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 Type B Deficiency is being cited based on LPAs' observation, interviews, record reviews pursuant to Title 22 of the CA Code of Regulations (refer to LIC 809-D). Site Supervisor was provided a copy of their Appeal Rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. A Notice of Site visit (LIC 9213) was given and must remain posted for 30 days or a civil penalty of $100 may apply.

Exit interview conducted and report was reviewed with the Facility representative Deri Kaye.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

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