343624352-8-8-2022-03-CC-ASUR-CH4NEZ-20220808102445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624352
Report Date: 08/08/2022
Date Signed: 08/08/2022 10:24:51 AM

Document Has Been Signed on 08/08/2022 10:24 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	KCE CHAMPIONS LLC @ CRES		FACILITY NUMBER:	343624352
ADMINISTRATOR:	AMY DODGE		FACILITY TYPE:	840
ADDRESS:	13580 JACKSON ROAD		TELEPHONE:	(530) 391-6816
CITY:	SLOUGHOUSE	STATE: CA	ZIP CODE:	95683
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	08/08/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Amy Dodge		TIME COMPLETED:	10:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Amanda Sutter met with Applicant Amy Dodge for the purpose of an announced pre-licensing inspection. Applicant requests a school-age license to serve 48 school-age children from kindergarten and above. The program will operate Monday through Friday 7:00 AM to 5:30 PM. The fire clearance was granted on 8/5/2022. Applicant acknowledges that the following documents must be posted at all times: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, Effects of Lead Exposure, car seat poster, menus, and daily schedule. LPA provided and discussed LIC311A and the forms that must be in each child's and each staff member's file. The facility will be providing a morning and afternoon snack. Breakfasts and lunches are provided by Consumnes River Elementary School. INDOOR ACTIVITY SPACE: There is one school-age classroom. LPA observed 11 chairs and 10 desks. LPA did not observe cubbies and applicant explained that the facility is using baskets that are in boxes and not yet assembled. LPA observed a variety of age-appropriate toys and equipment. There is a first aid kit in each of the classrooms. Medications will be stored in the locked cabinet by the front door. The facility did not yet have cleaning disinfectants. Applicant showed LPA where they would be stored in a locked cabinet, inaccessible to children. Applicant stated there are no poisons or firearms on the premises. Applicant stated that the facility plans to use a large jug of water and personal water bottles both in the classroom and on the playground. LPA observed a functional carbon monoxide detector. LPA observed a paper sign-in/sign-out system. Facility is located at an elementary school and is exempt from square footage requirements. Due to fire clearance approval of a capacity of 48 children, the classroom space is approved to accommodate 48 school-age children. There are 3 toilets and 4 sinks for the children. There are two restrooms that afford privacy and gender separation. Applicant stated that there is a separate private restroom for the staff by the school office. Children who become ill during the day will be isolated in the “quiet area” in the classroom and provided a cot. They will use the staff restroom, if necessary. Report continues on 809-C..

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC @ CRES	FACILITY NUMBER: 343624352
	VISIT DATE: 08/08/2022

NARRATIVE

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OUTDOOR ACTIVITY SPACE:
There are two school-age outdoor area on the property. The outdoor play area is fenced with a wrought iron fence that is six feet tall. LPA observed a variety of age-appropriate outdoor toys and equipment. The play structure includes a safety label, which designates use for children 5 to 12 years old. LPA observed bark beneath the structure and that there is enough cushioning material to absorb any falls. There are no bodies of water on the premises. There are shaded areas supplied by trees and overhangs. LPA discussed proper supervision with applicant for playground 2.

The facility's Plan of Operation is located in the administrative file. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department.

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.

LPA discussed the following: supervision; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. LPA discussed with Applicant any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

This facility evaluation report was reviewed and discussed with Applicant. Applicant was encouraged to the visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers.

The following items are required before a license will be issued:

1. Licensing Program Manager’s final file review.
2. Submit proof of adequate tables and chairs.
3. Proof of postings.
4. Proof of cleaned floors.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
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

LIC809 (FAS) - (06/04)

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