493010459-7-20-2023-01-CC-GOUE-CTWP9X-20230720110751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493010459
Report Date: 07/20/2023
Date Signed: 07/20/2023 11:08:03 AM

Document Has Been Signed on 07/20/2023 11:08 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	KCE CHAMPIONS LLC @ LIVE OAK		FACILITY NUMBER:	493010459
ADMINISTRATOR:	GILLUM, ASHLEY		FACILITY TYPE:	840
ADDRESS:	100 GNOSS CONCOURSE		TELEPHONE:	(925) 683-8326
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94952
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 60	CENSUS: 0	DATE:	07/20/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Melissa Jostedt and David Goad		TIME COMPLETED:	11:30 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) Glenn Ouye met with the Area Manager, Melissa Jostedt and Site Director, David Goad to conduct a prelicensing inspection. The application was received on June 12 2023. This school age program is located on the Live Oak Charter School located at the Petaluma Fairgrounds. The fire clearance clearance for the school and the school age program was approved on July 12, 2023 by The Department of Forestry and Fire Protection, Office of the Sate Fire Marshall. The program meets the exemption for Health and Safety Code Section 1596.806 regarding the square footage and toilet requirements, however there are sufficient toilets and sinks for the program. The program uses the After School Room and will have access to the Handiwork Room on an as needed basis. There are boys and girls restrooms just outside of the classroom. The girls bathroom has two toilets and two sinks. The boys bathroom has one toilet and one urinal and two sinks. There is a staff bathroom just off the kitchen area. All areas of the classroom will be on limits for the children. There are functioning smoke and carbon monoxide detector and two fire extinguishers rated at 3A40BC. The Handiwork room is the school's multipurpose room. The Area Manager and 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.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KCE CHAMPIONS LLC @ LIVE OAK	FACILITY NUMBER: 493010459
	VISIT DATE: 07/20/2023

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
26
27
28
29
30
31
32

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS has been 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.

The provider has the LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

The Area Director and the 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.

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 platforms. 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.

A notice of site visit will be given to the facility with all site visits except for prelicensing visits and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the Area Manager, Melissa Jostedt and Site Director, David Goad.

KCE Champions LLC @ Live Oak is approved for licensure effective today, July 20, 2023.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2