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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206848
Report Date: 09/20/2022
Date Signed: 09/20/2022 03:45:01 PM


Document Has Been Signed on 09/20/2022 03:45 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 @ MONTEREY ROADFACILITY NUMBER:
406206848
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:3355 MONTEREY ROADTELEPHONE:
(805) 952-5821
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:50CENSUS: 19DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Jacob LunaTIME COMPLETED:
04:00 PM
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On September 20, 2022 at 1:35 PM, Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced Annual/Random inspection. LPA met with Site Director Jacob Luna and advised him the purpose of the inspection. Director provided LPA a tour of the facility inside and out. There were 19 children in care at the facility at the time of the inspection.

Facility is located on a 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 classroom. Facility uses the school restrooms for children in care. The facility has a morning and afternoon program. LPA observed a facility snack schedule. Facility offers a morning and afternoon snack. LPA did not observe any hazards/toxins accessible to children in care. LPA observed age appropriate toys, activities, books, and furniture readily accessible for children to use. Facility uses the school outdoor recreation yard with toys and a play structure for the children to use. Children have access to water inside and out. The facility is sanitized daily by the school grounds janitorial staff.

LPA reviewed a sampling of children and staff records. Children records were found to be complete and current. Staff files were observed to be current and complete. Staff present were fully qualified with current Mandated Reporter and CPR/First-aid certificates. Facility is following current Covid-19 guidelines.

No deficiencies were cited during today's inspection.

Continued on 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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 @ MONTEREY ROAD
FACILITY NUMBER: 406206848
VISIT DATE: 09/20/2022
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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.

Director 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 Director
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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