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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215807
Report Date: 04/21/2021
Date Signed: 04/30/2021 08:01:18 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 @ VINEYARD ELEMENTARYFACILITY NUMBER:
406215807
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:2121 VINEYARD DRIVETELEPHONE:
(408) 348-1610
CITY:TEMPLETONSTATE: CAZIP CODE:
93465
CAPACITY:31CENSUS: 9DATE:
04/21/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Tamara Payne-AlexTIME COMPLETED:
09:30 AM
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On 4/21/2021 at 8:04 AM, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management Inspection of the School Age Center to license an additional classroom. LPA met with Area Manager, Tamara Payne-Alex and discussed the purpose of the visit. Due to COVID 19 and the California Department of Public Health guidelines for social distancing, this inspection was conducted virtually, via the Zoom application. Pre-Screening Tele-Inspection questions were asked and the responses provided by the Area Manager suggest the Center has no COVID exposures.

LPA Reyes accompanied by Area Manager toured the interior and exterior of the Center. There were 9 children and 3 Staff present during the inspection. The Center is located at Vineyard Elementary School in Templeton CA. Center submitted an application to add Room C-3 to the existing classrooms, Room D-1 and Multi Purpose Room. Room C-3 was observed to be clean and safe from hazardous items. LPA observed age appropriate furniture in the classroom. LPA observed the presence of fire extinguisher, carbon monoxide and smoke detectors.

Room C-3 was inspected and granted fire clearance on 3/31/2021 by Templeton Fire Department through Vineyard Elementary School request.

Continued on LIC 809C

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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 @ VINEYARD ELEMENTARY
FACILITY NUMBER: 406215807
VISIT DATE: 04/21/2021
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The School Age Center Room C-3 meets California Code of Regulation, Title 22 Division 12 and is licensed effective today, 4/21/2021.

During the course of the inspection, LPA discussed COVID-19 Mitigation plan, best practices, and its implementation in the School Age Center.

An exit interview was conducted with Area Manager and copy of this report was provided via email with a read receipt or confirmation of receipt which will act as the Area Manger's signature. signature.



LPA provided 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: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC809 (FAS) - (06/04)
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