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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206848
Report Date: 10/08/2019
Date Signed: 10/08/2019 02:32:04 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 @ MONTEREY ROADFACILITY NUMBER:
406206848
ADMINISTRATOR:JENNIFER HOKITFACILITY TYPE:
840
ADDRESS:3355 MONTEREY ROADTELEPHONE:
(805) 952-5821
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:50CENSUS: 7DATE:
10/08/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jennifer HokitTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Elvin Baddley and Melissa Stewart conducted an unannounced CASE MANAGEMENT inspection of the abovementioned facility. The LPAs met with Jennifer Hokit, Director of the facility to discuss an incident which was self reported to the Community Care Licensing Division on 10/7/19. The LPAs toured the area where the incident occurred.

The incident occurred on 9/27/19, at approximately 3:10 pm. The Director was supervising 13 children (school age) at the time of the incident. Circumstances of the incident involved six children being stung on the school site by wasps as they played in a grassy area near the restroom.

LPAs discussed the the content of the Unusual Incident Report (UIR) with the Director as well as the reporting of the incident to the parents children stung by the wasps and the CCLD. The Director stated she did not telephone CCLD following the incident. Further, the written UIR was not received by CCLD until 10/7/19.

This facility is being cited a type B deficiency according to California Code of Regulations, (Title 22, Division 12) on the attached LIC 9099 D.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin BaddleyTELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2019
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 @ MONTEREY ROAD
FACILITY NUMBER: 406206848
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2019
Section Cited

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Reporting Requirements-Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day...This requirement is not met as evidenced by:
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Based on interviews conducted and record review, the Director failed to advise CCLD of the incident via telephone after the occurance and written report was received after 7 days of the occurance.
This posed a potential risk to the health and safety of children in care.
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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 MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin BaddleyTELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2019
LIC809 (FAS) - (06/04)
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