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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313625081
Report Date: 08/09/2023
Date Signed: 08/09/2023 10:35:58 AM

Document Has Been Signed on 08/09/2023 10:35 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KCE CHAMPIONS LLC @ SKYRIDGE ELEMENTARYFACILITY NUMBER:
313625081
ADMINISTRATOR:SHELLY DUNCANFACILITY TYPE:
840
ADDRESS:800 PERKINS WAYTELEPHONE:
(916) 479-4977
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 75TOTAL ENROLLED CHILDREN: 75CENSUS: 0DATE:
08/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Amy Dodge TIME COMPLETED:
10:45 AM
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On August 9, 2023, LPA Perez, met with area manager Amy Dodge, for a change of location visit. Operating hours of the facility are from 6:30 am - 6:00 pm., Monday thru Friday. Area manager guided LPA on a tour of the room that will be licensed.
Room 20 will be licensed and utilized for the school aged program. A fire clearance has been granted to allot a capacity of 75 children.

All individuals subject to criminal background review have obtained criminal record clearance. Area manager is aware that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA observed the location of the restrooms, identified food services provided (snack provide, lunch provided upon request or brought from home), and outdoor play areas. Medications will be properly stored and inaccessible to children. Toxic and hazardous items will be inaccessible to children. Furniture and equipment are in good condition, free of hazards. LPA toured the outdoor playground area of the facility. The areas around or under climbing equipment are cushioned with sand. Toileting facilities are in safe, sanitary, and operating condition. Toilets have stall doors to provide privacy. Storage containers with solid waste will have tight-fitting lids. Drinking water was readily available inside the room, and children will bring their water bottles outside during recess.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KCE CHAMPIONS LLC @ SKYRIDGE ELEMENTARY
FACILITY NUMBER: 313625081
VISIT DATE: 08/09/2023
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Facility will place a parent board for all menus and notifications near the entrance of the facility. The facility will have authorized representatives sign children out when they are picked up. All children's files will be housed on site and accessible to licensing upon request.
LPA observed the correct size fire extinguisher with a current service tag. The facility will conduct fire drills at least once every six months. The fire alarm is connected to the school site and is in good working condition. Facility will provide licensing with Incidental Medical Services (IMS) information, if a child is on medication.

For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Effective today, August 9, 2023, this facility (room 20) is licensed for 75 school aged children.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Michelle Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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