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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215806
Report Date: 08/26/2021
Date Signed: 08/27/2021 03:58:52 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 @ TEMPLETON ELEMENTARYFACILITY NUMBER:
406215806
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:215 EIGHTH STREETTELEPHONE:
(408) 348-1610
CITY:TEMPLETONSTATE: CAZIP CODE:
93465
CAPACITY:31CENSUS: 21DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lily Ruelas TIME COMPLETED:
03:50 PM
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This Facility Evaluation Report issued on 8/26/2021 was generated on the wrong affiliated facility.

On August 26, 2021 at 2:00 PM, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Required Annual inspection of the above mentioned Child Care Center (CCC). Prior to inspection, LPA asked pre screening questions related to COVID 19, Site Supervisor's responses indicate there was no COVID 19 exposure on site. LPA met with Lily Ruelas, Site Supervisor and Teacher, Kaylee Degnan and explained the nature of the inspection. Center is located at Templeton Elementary School and utilizing the Multipurpose room of the school. There were 21 children present during the inspection.

During the tour, the following was observed, classroom is adequately equipped with age and size appropriate furniture and equipment. Drinking fountain supplies drinking water in the indoor activity space. Playground is enclosed by an appropriate fence. Outdoor activity area is free of hazard. Drinking water is provided in the outdoor play area by a water cooler and drinking fountain. Center implements California Department of Public Health Guidance for Child Care Programs.

A sampling of staff and children records were reviewed. The children’s records were complete and contain emergency contact information. A review of staff records on 8/26/2021 indicates that all facility staff have criminal record clearance. CPR and First Aid expires on 3/20/2023.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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 @ TEMPLETON ELEMENTARY
FACILITY NUMBER: 406215806
VISIT DATE: 08/26/2021
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Sign in and sign out record meets the regulation requirements. AB 1207 Mandated Reporter Training Certificate was taken on 4/9/2021. Site Supervisor and Staff qualifications were verified.

Site Supervisor noted no firearms or ammunition is stored on site.

Incidental Medical Services (IMS) policy was discussed. 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.htmhttp://www.ada.gov/childqanda.htm

In areas evaluated, no deficiency was cited.



Exit interview was conducted with Site Supervisor, Lily Ruelas. THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL BE ASSESSED.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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