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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215258
Report Date: 10/17/2022
Date Signed: 10/17/2022 12:58:07 PM


Document Has Been Signed on 10/17/2022 12:58 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 @ 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: 8DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bridget MilesTIME COMPLETED:
11:34 AM
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On October 17, 2022 at 10:13 AM, Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced Annual/Random inspection. LPA met with facility Director Bridget Miles and advised her the purpose of the inspection. Director provided LPA a tour of the facility inside and out. There were eight (8) children in care at the time of the inspection. This is a combined facility with School-age program.

The facility is located on a local elementary school. The facility is using one (1) classroom for children in care. LPA observed licensing required documents posted prominently on the wall in view. Facility has enough restrooms for children in care. LPA observed a facility snack schedule. Facility offers a morning and afternoon snack. Children bring their lunches from home or have the option to get a hot lunch from the school cafeteria. LPA did not observe any hazards/toxins items accessible to children in care. The classroom has age appropriate toys and furniture readily accessible for children in care. Facility provides children that are staying full day a sleeping cot during quiet time if they choose to sleep. Children bring their own linen from home. Facility shares the the outdoor playground with the school Kindergarten class on a staggered schedule. The outdoor playground has an ample amount of space and shade for children to play. LPA observed the playground has age appropriate toys and structures available for children to use. The facility has water available for children inside and out. Children use their own water bottles brought from home.

A sampling of children and staff records were reviewed. LPA observed children and staff files to be complete and current. Teachers meet the required qualifications. Teachers present have current Pediatric CPR/First-Aid certificates.

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: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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 @ SANTA ROSA PS
FACILITY NUMBER: 406215258
VISIT DATE: 10/17/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Home Section 102417. When any IMS is provided, a plan for providing 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.

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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