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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010058
Report Date: 07/16/2021
Date Signed: 07/16/2021 11:25:48 AM

Document Has Been Signed on 07/16/2021 11:25 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:KCE CHAMPIONS LLC @ MARY COLLINSFACILITY NUMBER:
493010058
ADMINISTRATOR:MEJIA, TANIAFACILITY TYPE:
840
ADDRESS:1001 CHERRY STREETTELEPHONE:
(707) 332-2583
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 45TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Melissa Jostedt and Tania MejiaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Glenn Ouye met with Melissa Jostedt and Tania Mejia at KCE Champions LLC @ Mary Collins to conduct a prelicensing inspection of the Mary Collins school age before and after school program. The program will operate as follows: Kindergarteners can attend from 6am to 8:20am daily and 12:45pm to 6:00pm daily. The age group above kindergarten will operate from 6am to 8:20am and 2:30pm to 6pm daily except Wednesdays which will operate from 12:45pm to 6pm. Hours may change as it can be impacted by Covid-19 changes by local or state public health department or the needs of the program and or school district. This program has two classrooms. One for kindergarten age children and another classroom for children older than kindergarten. Each classroom has it's own bathrooms. There is a teachers lounge for the staff. There is also a staff restroom.

The children will have access to the large field and outdoor play structure as an outdoor activity area in front of the program classrooms. There is also a second outdoor activity area with a play structure and gardening area for the children. Children will use personal water bottles for hydration while at the program.

The fire safety inspection was approved by the Petaluma Fire Department on June 2, 2021. There are functional smoke detectors, carbon monoxide detectors and fire extinguishers in both classrooms.

Required posting will be posted in both classrooms. LPA Ouye and Ms. Jostedt discussed Covid-19 mitigation protocols regarding health screening/check-in procedures, face masking, hygiene and classroom sanitization.

There are sufficient tables, chairs, equipment and toys for the school age children.

The applicant agrees to provide the department with a copy of the ratified contract after licensure.

This program is approved for licensure effective July 16, 2021.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
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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