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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215258
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:13:42 PM

Document Has Been Signed on 12/03/2024 12:13 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 ROSA PSFACILITY NUMBER:
406215258
ADMINISTRATOR/
DIRECTOR:
TAMARA PAYNE-ALEXFACILITY TYPE:
850
ADDRESS:8655 SANTA ROSA ROADTELEPHONE:
(805) 712-9485
CITY:ATASCADEROSTATE: CAZIP CODE:
93423
CAPACITY: 23TOTAL ENROLLED CHILDREN: 23CENSUS: 6DATE:
12/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:16 AM
MET WITH:Shameka CullorsTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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On 12/3/24, at 10:16 AM, Licensing Program Analysts (LPAs) Elvin Baddley and Matthew Sapien conducted an unannounced Annual Random Inspection the abovementioned Child Care Center (CCC). LPA met with Shameka Cullors, Site Supervisor of the CCC, and explained the nature and purpose of the inspection. LPAs, in the company of the Site Supervisor, toured the interior and exterior of the CCC. The CCC operates out of classroom 204 on the grounds of Santa Rosa Academic Academy. The CCC's hours of operation are 7:00 AM until 6:00 PM Monday through Friday. During the inspection, LPAs observed six children in care along with two other staff members (cleared and associated).

The classroom of the CCC is clean and orderly. The classroom has age appropriate toys, books, and other furnishings for children in care. The CCC does not currently have an operational refrigerator, but utilizes classroom 1702's refrigerator for children in care. The CCC provides morning and afternoon snacks for children in care, while lunches are brought from home. There is available drinking water for children in the CCC via a water dispenser. Children also bring bottled water from their respective homes.

CCCs constructed before 1/1/20, to test their water (used for drinking and food preparation) for lead contamination before 1/1/23, and then every 5-years except after the date of the first test. For child care center licenses issued after 7/1/22, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPAs verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

LPAs observed snack menus and required notices and other relevant documents posted prominently on classroom walls. LPAs also reviewed the children's sign in/sign out forms and found the arrival times of children, along with the departure times. The signatures of authorized representatives were also present.

(CONT. LIC 802-C)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Matthew Sapien
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: KCE CHAMPIONS LLC @ SANTA ROSA PS
FACILITY NUMBER: 406215258
VISIT DATE: 12/03/2024
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LPAs observed a carbon monoxide detector in classroom 204, which was tested at 10:48 AM, and was found to be operable. Cleaning compounds and chemicals are stored in a locked cabinet beneath the sink in the CCC. No medication is currently used by children, however, the CCC does possess a secure lock box for said items. Sharps, like scissors, were also observed in a cabinet at the teacher's desk inaccessible to children in care. The CCC also has a First Aid kit that contains gloves, band-aids, and other appropriate supplies.

The restrooms of the CCC are located on the elementary school ground, outside of the classroom.
All restrooms are in sanitary operating condition. The CCC shares the restrooms with other children in the school, however, the children are monitored by CCC staff when using the restrooms.

Children in care have access to two outdoor playground areas, both of which are enclosed by chain linked fencing. The fence’s entry/exit gates are secure and furnishings in the area are age appropriate. The play structures in the outdoor play area have adequate cushioning material (wood bark and sand) to absorb falls. Children also have access to basketball courts and other blacktop areas for play. Play times in the outdoor area are staggered to ensure children in care do not commingle with school age children. Shade is provided by building overhangs in the area. No bodies of water were observed on site.

Staff and children records were reviewed. The children’s records were complete and found to contain emergency contact information as well admission agreements, among other relevant licensing documents and forms. Staff records were reviewed and contained current pediatric CPR and First Aid certifications (EMSA approved), along with Mandated Reporter certifications. Facility records show the last fire drill on site occurred on 11/15/24. LPAs confirmed that there are no firearms or ammunition are stored on site.

This facility does not currently provide Incidental Medical Services – IMS. For IMS information see PIN 22-02-CCP. 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 are available at: https://www.ada.gov/resources/child-care-centers/.

Facility representative was reminded that all adults 18 and over, including employees and volunteers,
(CONT. 809-C, Page 3)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Matthew Sapien
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: KCE CHAMPIONS LLC @ SANTA ROSA PS
FACILITY NUMBER: 406215258
VISIT DATE: 12/03/2024
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as specified in HSC 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.

Facility representative was informed of the MyChildCarePlan.org website; 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.

To improve the quality and value of the new inspection process, a survey may be sent to the email address
provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Facility representative, Shameka Cullors.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Matthew Sapien
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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