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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206846
Report Date: 06/01/2026
Date Signed: 06/01/2026 01:05:26 PM

Document Has Been Signed on 06/01/2026 01:05 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:KCE CHAMPIONS LLC @ SANTA MARGARITAFACILITY NUMBER:
406206846
ADMINISTRATOR/
DIRECTOR:		D.K. VACAFACILITY TYPE:
840
ADDRESS:22070 H STREETTELEPHONE:
(805) 703-3508
CITY:SANTA MARGARITASTATE: CAZIP CODE:
93453
CAPACITY: 26TOTAL ENROLLED CHILDREN: 26CENSUS: 11DATE:
06/01/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Taylor BrownTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 6/1/26, at 12:00 PM, Licensing Program Analyst (LPA) Matthew Sapien made an unannounced Case Management (Incident) inspection at the abovementioned Child Care Center (CCC). LPA met with Taylor Brown, Facility Representative of the CCC, and explained the nature and purpose of the inspection. LPA, in the company of the Facility Representative, toured the CCC. At the time of the inspection, LPA observed 11 children in care. In addition to the Facility Representative of the CCC, LPA also observed 5 staff assistants present on site (cleared and associated). Importantly to note, the CCC is on the grounds of the Santa Margarita Elementary School.

This Case Management inspection follows an Unusual Incident at the CCC which occurred on 5/14/26. The incident was reported to the Department on 5/15/26 through a telephone call. LPA reminded the Facility Representative of the timelines to follow when it comes to reporting requirements of incidents. The CCC operates Monday through Thursday from 7:00 AM until 11:20 AM and then 11:40 AM to 6:00 PM. On Fridays, the CCC operates from 7:00 AM until 10:20 AM and then from 11:40 AM until 6:00 PM.

In regards to the incident, on 5/14/26, Child 1 (will hereby be referenced as "C1"), was playing on the playground. While using a short slide on the playground, C1 jumped, fell off, and landed on their left arm. At first, the fall did not result in any swelling or bruising. After the fall, Staff Member 1 and Staff Member 2 (will hereby be referenced as "S1" and "S2") quickly picked up the child and consoled them. Staff sat down with C1 and provided an ice pack. After about 15 minutes, C1 felt fine enough to continue outdoor play. On-site staff notified the parents of C1 who later arrived to the CCC to pick up their child about thirty minutes after the fall. On 5/15/26, the parents of C1 took C1 to the doctor where it was determined there was a break in the elbow of C1. (CONT. LIC 809-C, Page 2)

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2026
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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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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: KCE CHAMPIONS LLC @ SANTA MARGARITA
FACILITY NUMBER: 406206846
VISIT DATE: 06/01/2026
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During today's visit, 6/1/26, LPA toured the facility and placed a particular emphasis on the area where the incident occurred (outdoor playground and slide area). LPA also had in-depth conversation with the Facility Representative and other staff members. LPA determined the fall to be an accident rather than a lack of proper care, supervision, or adequate cushioning in the play yard. Important to note, the surface of the outdoor playground area is made up of a non-loose firm rubber surfacing. LPA reminded the staff of the importance of active supervision over children in care and to report any incidents in a timely manner as they arise.

The Facility Representative was provided a copy of their Appeal Rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Facility Representative, Taylor Brown. Facility Representative was provided with a Notice of Site Visit (LIC 9213). The Notice of Site Visit form must be posted for 30 days or a civil penalty of $100 may apply.

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2026
LIC809 (FAS) - (06/04)
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