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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
493010058
Report Date:
04/12/2022
Date Signed:
04/12/2022 01:03:50 PM
Document Has Been Signed on
04/12/2022 01:03 PM
- 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
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
KCE CHAMPIONS LLC @ MARY COLLINS
FACILITY NUMBER:
493010058
ADMINISTRATOR:
MIKAYLA SPAIN
FACILITY TYPE:
840
ADDRESS:
1001 CHERRY STREET
TELEPHONE:
(707) 364-6229
CITY:
PETALUMA
STATE:
CA
ZIP CODE:
94952
CAPACITY:
45
TOTAL ENROLLED CHILDREN:
45
CENSUS:
DATE:
04/12/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:00 PM
MET WITH:
Melissa Jostedt
TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Glenn Ouye met with Melissa Jostedt to conduct a case management visit for the purpose of a capacity increase. The fire inspector was at the site earlier today. There are some items that the licensee will be completing prior to the fire inspection approval. The fire inspection has not been approved yet.
The Champions program will will be adding two new room to served the younger school age children who are of Transitional Kindergarten age. The rooms that are being utilized are Manzanita Room 1 and the MPR building called the Lodge. There is an outdoor area that will be dedicated to this age group.
The Champions program expects to start the program in July 2022. The school is currently occupying the two new rooms. The rooms will be converted to the Champions program when the school breaks and furniture will be installed. Part of the retaining wall is broken and is in need of repair prior to the department approving the use of the Manzanita Room 1 playground for use.
The capacity increase will be approved after the repair of the retaining wall is completed and receipt of the approved fire clearance from the Petaluma Fire Department is received.
No deficiencies cited during the site visit.
SUPERVISORS NAME
:
Leslie Lepori
LICENSING EVALUATOR NAME
:
Glenn Ouye
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/12/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/12/2022
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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