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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215258
Report Date: 09/02/2021
Date Signed: 09/02/2021 01:26:58 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 PSFACILITY NUMBER:
406215258
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
850
ADDRESS:8655 SANTA ROSA ROADTELEPHONE:
(805) 712-9485
CITY:ATASCADEROSTATE: CAZIP CODE:
93423
CAPACITY:23CENSUS: 9DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Bridget MilesTIME COMPLETED:
01:30 PM
NARRATIVE
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On 9/2/2021 at 11:20am, Licensing Program Analyst (LPA) Melissa Stewart arrived at the Santa Rosa Academy Academy campus office. At 11:40am, LPA met with Facility Representative, Bridget Miles, outside of classroom #204 where she was supervising nine (9) children who were eating lunch at a picnic table under a large tree. The purpose and nature of the Required- 1 year inspection was explained. The preschool operates, Monday - Friday, 7am - 5:30pm. All required forms, including monthly menu, are posted on the wall at the back exit of the classroom. The number of children signed in by parents corresponded with the number of children present.

The classroom was observed to be clean, organized and free of toxins. There are various activity centers containing books, puzzles, manipulatives, blocks, arts and crafts and dramatic play materials. Drinking water is available both inside via drinking faucet and outside via individual water bottles. The first aid kit is located in a cabinet mounted on the wall near the sink inside the classroom. Detergents, cleaning compounds, medications and other items such as kitchen knives which could pose a danger to children are stored inaccessible to children. The boys and girls restrooms are reserved exclusively for use by Champions preschool program and are located to the right as you exit the classroom toward the a outdoor activity area. S2 arrived at approximately 12:10pm and accompanied Bridget Miles and the children indoors to wash hands. S2 reported that the most recent drill was held on 8/31/21. The carbon monoxide detector was tested and found to be operational.

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. Continued on 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (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 PS
FACILITY NUMBER: 406215258
VISIT DATE: 09/02/2021
NARRATIVE
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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

A sample of children's files and staff files were reviewed at 12:25pm. Both staff have current Pediatric CPR and First Aid certification expiring in August 2023. Both staff have met immunization requirements per SB 792 and completed AB 1207 Mandated Reporter Training within the last two (2) years. Bridget Miles is a fully qualified preschool director and completed Universal Precautions Training on 2/15/2021. S2 did not have a Health Screening and record of negative tuberculosis test on file.

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.

Deficiency cited today in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with 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 MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (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)
Page: 3 of 3
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 PS
FACILITY NUMBER: 406215258
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2021
Section Cited

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(g)All personnel, ... shall be in good health ...(1) ... good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This requirement is not met as evidenced by:
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Based on file review and interview, S2 has completed a health screening and TB test with negative result, but has not received the documentation from the physician's office. Licensee did not ensure that S2 had verification of good health and begative TB on file for review by LPA which poses a potential risk to the health and or safety of children.
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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: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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