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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
406215807
Report Date:
08/26/2021
Date Signed:
08/30/2021 08:50:32 AM
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 ELEMENTARY
FACILITY NUMBER:
406215807
ADMINISTRATOR:
TAMARA PAYNE-ALEX
FACILITY TYPE:
840
ADDRESS:
2121 VINEYARD DRIVE
TELEPHONE:
(408) 348-1610
CITY:
TEMPLETON
STATE:
CA
ZIP CODE:
93465
CAPACITY:
31
CENSUS:
21
DATE:
08/26/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Lily Ruelas
TIME COMPLETED:
03:50 PM
NARRATIVE
1
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7
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9
10
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21
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Created in error.
SUPERVISOR'S NAME:
Maria Mueller
TELEPHONE:
(805) 562-0410
LICENSING EVALUATOR NAME:
Gigi Reyes
TELEPHONE:
(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)
Page:
1
of
2
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:
08/26/2021
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
26
27
28
29
30
31
32
Created in Error.
SUPERVISOR'S NAME:
Maria Mueller
TELEPHONE:
(805) 562-0410
LICENSING EVALUATOR NAME:
Gigi Reyes
TELEPHONE:
(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)
Page:
2
of
2