406215479-12-16-2019-17-CC-GRES-BJWSHA-20191216125314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406215479
Report Date: 12/16/2019
Date Signed: 12/16/2019 12:53:19 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 @ SAN GABRIEL PS		FACILITY NUMBER:	406215479
ADMINISTRATOR:	DERI KAYE RIPEL		FACILITY TYPE:	850
ADDRESS:	8500 SAN GABRIEL ROAD		TELEPHONE:	(805) 952-5083
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	23	CENSUS: 5	DATE:	12/16/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Deri Kaye Ripel/Kayleen Moore		TIME COMPLETED:	12:55 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	Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced annual random and met with Teacher, Ms. Kayleen Moore, Site Director arrived afterwards. There were 5 children present during the Visit. The purpose of the inspection was discussed. Preschool is located at San Gabriel Elementary School and occupies room 1006. The Center was toured inside and out. Classroom is adequately equipped with age and size appropriate furniture. Drinking fountain supplies drinking water in the classroom. Outdoor activity area is enclosed with appropriate fence. Drinking water is provided in the outdoor play area with water fountain. Each child also brings water bottle in the playground. Toxins are kept inaccessible to day care children. Bathrooms were observed to be clean. LPA did not observe bodies of water. Ms.Ripel stated there are no guns nor ammunition in the Center. CPR and First Aid expires on 8/7/2021. Teachers have met the SB 792, immunization records are on file. AB 1207 Mandated Reporter Training was completed by the staff. Staff were informed that AB 1207 is subject for renewal every two years. Teachers qualifications were verified. LPA observed licensing forms are posted in the prominent location. Sign in Sign out was checked and found complete. Children's files were randomly reviewed. Center is not providing Incidental Medical Services. (IMS) IMS policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. Continued on 809 C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2019

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 @ SAN GABRIEL PS	FACILITY NUMBER: 406215479
	VISIT DATE: 12/16/2019

NARRATIVE

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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

During today's visit no deficiency was cited.

LPA observed director posted the Notice of Site Visit.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2019

LIC809 (FAS) - (06/04)

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