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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313624341
Report Date: 08/08/2022
Date Signed: 08/08/2022 02:19:18 PM

Document Has Been Signed on 08/08/2022 02:19 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:KCE CHAMPIONS LLCFACILITY NUMBER:
313624341
ADMINISTRATOR:SHELLY DUNCANFACILITY TYPE:
850
ADDRESS:173 OAK STTELEPHONE:
(916) 479-4977
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 75TOTAL ENROLLED CHILDREN: 75CENSUS: 0DATE:
08/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shelly DuncanTIME COMPLETED:
02:45 PM
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LPAs Lea Habtom and Amanda Blesi conducted a site visit for the purpose of a pre-licensing evaluation. LPAs met with Area Manager Shelly Duncan. Applicant requests a school-age license to serve 75 children in an after school program on the Alta Vista community charter school campus rooms 5, 11, 15 and the multipurpose room. Program hours are Monday through Friday 6:30 am to 6 pm. This program will be serving TK children. Naps will not be provided.

The facility has a copy of the following documents posted in a conspicuous area: Parents' Rights Poster,
Personal Rights, Car Seat Law, Emergency Disaster Plan, and the snack menu.

INDOOR ACTIVITY SPACE:
The room is equipped with child size furnishings with age-appropriate play equipment. There are individual hooks along the wall for storing children's personal belongings. The first aid kit is located in the storage cabinet and medications will be stored in a locked box in the room. There is a drinking fountain for water located in the classrooms. The program will also carry an igloo water container.

According to Title 22, Division 12, Sections 101538.2 (c) & 101538.3 (c), the school-age program is exempt from the indoor and outdoor square footage as well as the restroom requirements.

OUTDOOR ACTIVITY SPACE:
The after school program will use Alta Vista community charter school campus outdoor play area which is fenced and equipped with age-appropriate play equipment. There is sufficient resilient material underneath climbing structures. There is a field that belongs to the school that is fully fenced.

Upon return to the licensing office, a final review of the facility file will be conducted by the LPA and LPM for a school-age license to serve 75 children. Fire clearance separate from school was granted on 7/20/2022.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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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