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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010057
Report Date: 09/08/2021
Date Signed: 09/08/2021 10:58:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:KCE CHAMPIONS LLC @ VALLEY VISTAFACILITY NUMBER:
493010057
ADMINISTRATOR:JUNIOR, TIFFANYFACILITY TYPE:
840
ADDRESS:730 N. WEBSTER STREETTELEPHONE:
(925) 457-7138
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:60CENSUS: 0DATE:
09/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Melissa JostedtTIME COMPLETED:
11:15 AM
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Area Manager Melissa Jostedt met with Licensing Program Analyst. The purpose of the case management visit was to address and confirm the removal of two classrooms from the facility program. Valley Vista Elementary School has taken back classrooms three and four to use for their Pre-K classes.

The facility will use the Child Care Classroom as the primary class and will also use the MPR (multipurpose room) for indoor space. The outdoor area is unchanged.

A new sketch was provided to the department. There is no change to capacity or the fire clearance.

No deficiencies cited during the site visit.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn OuyeTELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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