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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394501552
Report Date: 04/22/2025
Date Signed: 04/22/2025 12:32:41 PM

Document Has Been Signed on 04/22/2025 12:32 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KCE CHAMPIONS LLC @ TLC (GRANT LINE)FACILITY NUMBER:
394501552
ADMINISTRATOR/
DIRECTOR:		FULTZ, SANDYFACILITY TYPE:
860
ADDRESS:238 W GRANT LINE ROADTELEPHONE:
(916) 833-7982
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 0DATE:
04/22/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Punam MisraTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Centralized Application Bureau (CAB) Licensing Program Analyst (LPA) Alecia Sifuentes met with Site Director Punam Misra for the purpose of a prelicensing inspection. The facility is located in Building B where the church is located in Building A. LPA has on file that Area Manager Sandy Fultz is the designated director for this location. LPA informed Punam that a new Site Director packet will need to be submitted to the department when the facility is ready to make the director change. Applicant requests a school-age component to serve 40 school-age children from TK to 12 years. The program will operate Monday through Friday from 3:15 p.m. to 6:00 p.m and in the summer from 7:00 a.m. to 5:30 p.m. The fire clearance was granted and received on 4/18/2025. The facility will be providing morning and afternoon snacks and parents will provide the lunch.

LPA reviewed with Site Director the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

INDOOR ACTIVITY SPACE:
There are two school-age classrooms located in Room A and Room B. LPA observed a sufficient amount of equipment, tables, chairs, and cubbies. There is a first aid kit in each classroom near the exit doors in a stroller bag. Medications will be stored in the fridge in the kitchen. LPA observed cleaning disinfectants are appropriately stored and inaccessible to children. Applicant stated there are no poisons or firearms on the premises. LPA observed a water pitchers and cups for children through out the day. LPA observed a functional carbon monoxide detector in Room B. LPA observed a paper sign in/sign out system.

Report continues on LIC809-C page 2.

NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Alecia Sifuentes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KCE CHAMPIONS LLC @ TLC (GRANT LINE)
FACILITY NUMBER: 394501552
VISIT DATE: 04/22/2025
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Page 2.

LPA measured the school-age classrooms. The total classroom spaces contain a total of 3,635 square feet, which will accommodate Applicant's request for 40 school-age children. There are seven toilets and nine sinks for the children, and a separate private restroom for the staff located in Room A. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the staff area or office area and will use the staff restroom, if necessary.

OUTDOOR ACTIVITY SPACE:
There is one school-age outdoor area on the property. The outdoor play area is fenced with a wooden and wrought iron fence that is at least four feet tall. LPA observed a sufficient amount of equipment and toys. The play structure includes a safety label, which designates use for children 2 years and above. There are no bodies of water on the premises. There are shaded areas supplied by trees and a canopy.

LPA measured the outdoor activity space. The outdoor play area contains a total of 5,232 square feet, which will accommodate Applicant's request for 40 school-age children. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A 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) or (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 Site Director 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.

Report continues on LIC809-C page 3.

NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Alecia Sifuentes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KCE CHAMPIONS LLC @ TLC (GRANT LINE)
FACILITY NUMBER: 394501552
VISIT DATE: 04/22/2025
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Page 3.

Site Director was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Site Director was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Written Directives for Lead Testing in Child Care Centers: Assembly Bill 2370, Chapter 676, Statutes of 2018, added Health and Safety Code section 1597.16 requiring all licensed Child Care Centers constructed before January 1, 2010, test their water for lead between January 1, 2020 and January 1, 2023, and then every 5 years after the date of the first lead testing. For a license issued on or after July 1, 2022, initial testing results shall be received and posted within 180 days of licensure. Site Director stated that water used for consumption is purchase only. No sinks are used.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with Site Director Punam Misra.

Effective today, 4/22/2025, the facility is approved for 40 school-age children.

NAME OF LICENSING PROGRAM MANAGER: Monica Cuddy
NAME OF LICENSING PROGRAM ANALYST: Alecia Sifuentes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4