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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215479
Report Date: 06/10/2022
Date Signed: 06/10/2022 02:59:32 PM


Document Has Been Signed on 06/10/2022 02:59 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 @ SAN GABRIEL PSFACILITY NUMBER:
406215479
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
850
ADDRESS:8500 SAN GABRIEL ROADTELEPHONE:
(805) 952-5083
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:23CENSUS: 7DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Amy SoylandTIME COMPLETED:
03:14 PM
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On June 10, 2022 at 1:02 PM, Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced Annual/Random inspection. LPA met with facility Teacher Amy Soyland and advised her the purpose of the inspection. Teacher provided LPA a tour of the facility inside and out. There were seven (7) children in care and two (2) staff at the time of the inspection. This is a combined facility with a School-age program.

LPA observed required licensing documents mounted on the wall at the entrance of the facility. LPA observed a snack menu on the wall. The facility provides two snacks for children in care. Currently children bring their lunch from home during the Summer program. During the normal school year, parents have the option to use the school lunch program. The center uses the school restrooms for children in care. The children are escorted to the restroom when needed. The center uses one (1) classroom for children in care. LPA did not observe any hazards/toxins items accessible to children in care. Classroom has age appropriate toys, books, activities, and furniture readily accessible for children in care. Children are provided a sleeping mat if they choose to sleep during quiet time. The center uses the school blacktop and grass area for children to play outside. The facility has water available for children inside and out. Children use their own water bottles brought from home or a paper cup is provided if a child does not have a personal cup.

A sampling of children and staff records were reviewed. LPA observed children's files to be complete and current. LPA observed staff files to be complete and current. Teachers meet the required qualifications. Teachers present have current Pediatric CPR/First-Aid and Mandated Reporter certificates. LPA spoke with Teacher about new Covid-19 guidelines. Facility is currently following 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: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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 @ SAN GABRIEL PS
FACILITY NUMBER: 406215479
VISIT DATE: 06/10/2022
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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 Teacher
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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