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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010693
Report Date: 05/22/2026
Date Signed: 05/22/2026 02:56:58 PM

Document Has Been Signed on 05/22/2026 02:56 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 ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KCE CHAMPIONS LLC @ TWO ROCKFACILITY NUMBER:
493010693
ADMINISTRATOR/
DIRECTOR:		BLACK, EMILYFACILITY TYPE:
860
ADDRESS:5001 SPRING HILL ROADTELEPHONE:
(707) 241-5899
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 60TOTAL ENROLLED CHILDREN: 33CENSUS: 3DATE:
05/22/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:33 AM
MET WITH:Emily BlackTIME VISIT/
INSPECTION COMPLETED:
03:09 PM
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A required annual inspection of the facility was conducted by Licensing Program Analyst (LPA) Robert Maciel-Kashima, who met with Director Emily Black. The facility file was reviewed prior to this inspection. A review of the personnel report on file indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over, 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.

The facility’s operating hours are from 12 p.m. to 6 p.m., Monday-Friday. The facility was toured inside and outside and the floor and yard plan submitted by the licensee were verified. The sign-in/sign-out records were reviewed. Items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be stored inaccessible to children. Director stated poisons are not stored on site and none were observed by LPA. The toys, floors, desks and other equipment and surfaces are clean, toxic free, safe and in good condition. There is uncontaminated drinking water available to children indoors and outdoors by use of individual water bottles and outdoor fountains. The children's bathrooms are in safe and sanitary condition. The facility provides afternoon snacks. Food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. Garbage cans containing solid waste have tight fitting lids. LPA observed a working carbon monoxide detector, smoke alarm, and fire extinguisher rated at least 2A10BC in the facility. Director stated the last emergency drill was conducted on 5/11/26 but was not recorded. Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2026
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 ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KCE CHAMPIONS LLC @ TWO ROCK
FACILITY NUMBER: 493010693
VISIT DATE: 05/22/2026
NARRATIVE
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The playground equipment and surface areas are in safe condition. There is wood chip cushioning underneath climbing structures and/or play equipment to absorb falls. There are no bodies of water observed on the site. Director stated no weapons are stored on site, and none were observed. During today's inspection, 3 children were present. The facility was operating within the licensed capacity and ratio requirements. During today's visit, no staff member present during the inspection possessed current CPR and First Aid certifications. Five children’s records (C1-C5) were reviewed which revealed that the facility did not possess record of C1, C2, C3, and C5's LIC700 identification and emergency information form, LIC627 consent for emergency medical treatment form, LIC613A Receipt for personal rights, and LIC995 receipt for notification of parent's rights form. Two staff records (D1, S1) were reviewed which revealed that no staff possessed current mandated reporter training certificates and the facility did not possess record of S1's LIC503 Health screening form.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Incidental Medical Services – IMS policy was discussed. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and
administrative records. 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/.

Licensee 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.

Continued on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
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 ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KCE CHAMPIONS LLC @ TWO ROCK
FACILITY NUMBER: 493010693
VISIT DATE: 05/22/2026
NARRATIVE
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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 atwww.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

The following violations of the California Code of Regulations, Title 22, were cited during today's inspection, see LIC809-D. Appeal rights were provided. Exit interview given and report was read with Director Emily Black. A notice of site visit was given and must remain posted for 30 days. Failure to do so shall result in an immediate civil penalty of $100.
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2026 02:56 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/22/2026 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KCE CHAMPIONS LLC @ TWO ROCK
FACILITY NUMBER: 493010693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and Director statement,the facility performed a disaster drill on 5/11/26 but did not record the drill which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2026
Plan of Correction
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Director stated the facility would perform a disaster drill, record it on a drill log, and submit a copy of the drill log to LPA by email at robert.maciel-kashima@dss.ca.gov by 6/22/26.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, no staff possessed current mandated reporter training certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2026
Plan of Correction
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Director stated she would obtain a current mandated reporter training certification for D1 and S1 and send a copy to LPA by email at robert.maciel-kashima@dss.ca.gov by 6/22/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Robert Maciel
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2026 02:56 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/22/2026 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KCE CHAMPIONS LLC @ TWO ROCK
FACILITY NUMBER: 493010693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, no staff member present during the inspection possessed current CPR and First Aid certifications which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2026
Plan of Correction
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Director stated she would obtain a current 1st aid/cpr certification and send a copy to LPA by email at robert.maciel-kashima@dss.ca.gov by 6/22/26.
Type B
Section Cited
CCR
101217(d)
Personnel Records
(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not possess record of S1's LIC503 Health screening form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2026
Plan of Correction
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Director stated she would obtain S1's LIC503 and send a copy to LPA by email at robert.maciel-kashima@dss.ca.gov by 6/22/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Robert Maciel
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/22/2026 02:56 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/22/2026 at 01:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KCE CHAMPIONS LLC @ TWO ROCK
FACILITY NUMBER: 493010693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the facility did not possess record of C1, C2, C3, and C5's LIC700 identification and emergency information form, LIC627 consent for emergency medical treatment form, LIC613A Receipt for personal rights, and LIC995 receipt for notification of parent's rights form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/22/2026
Plan of Correction
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Director stated she would obtain all missing child file documents for C1, C2, C3, and C5 and submit a copy to LPA by email at robert.maciel@dss.ca.gov by 6/22/26.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Robert Maciel
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2026


LIC809 (FAS) - (06/04)
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