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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493011058
Report Date: 03/24/2026
Date Signed: 03/24/2026 12:07:07 PM

Document Has Been Signed on 03/24/2026 12:07 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 AT PENNGROVE ELEMENTARYFACILITY NUMBER:
493011058
ADMINISTRATOR/
DIRECTOR:		MATT ROARKFACILITY TYPE:
860
ADDRESS:365 ADOBE ROADTELEPHONE:
(707) 780-8798
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 150TOTAL ENROLLED CHILDREN: 150CENSUS: 0DATE:
03/24/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Christopher SachenTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 03/24/2026, Centralized Application Bureau (CAB) Licensing Program Analyst (LPA) Jaelyn Agbayani and LPA Yang Yang met with Center Director, Christopher Sachen and Licensee Representative, Matthew Roark. The purpose of the visit was an announced pre-licensing inspection at the facility to ensure that health, safety and personal rights as required by Title 22 and Health and Safety Regulations governing California Child Care Centers will be met. This is an application for 150 School Age Children (ages 4-13 years old) in The Basement, Multipurpose Room, and Classrooms 18 and 19. The childcare center will operate Monday, Tuesday, Thursday, and Friday from 1:35 PM to 6:00 PM, Wednesday 11:35 AM to 6:00 PM when school is in session. Break camps will operate 8:00 AM to 6:00 PM. The fire clearance was approved on 11/18/2025. There were no children present during this inspection.

Per Health and Safety Code Health and Safety Code Sections 1596.806(a), (a)(1), (a)(2), (b), (b)(1) and (d) state: (a) A room used as a classroom by a schoolage child care program shall not be required to meet the square footage or toilet requirements for child day care centers if the program is operated on either of the following: (1) A functioning schoolsite in the same facilities that have housed school children during the day, before or after school hours, or before and after school hours. (2) A functioning schoolsite in facilities certified as usable as a classroom for instruction. Per Licensee Representative Matthew Roark providing a signed document by the Chief Business Official of Petaluma City School’s Certification for Approval to operate on the school grounds of Penngrove Elementary School, this facility meets Title 22’s Health and Safety Code listed above.

Report continued on LIC 809-C.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2026
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 AT PENNGROVE ELEMENTARY
FACILITY NUMBER: 493011058
VISIT DATE: 03/24/2026
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LPAs toured the on-limits areas and classrooms located at the facility. The facility has a total of 3 classrooms, a multipurpose room, and 2 play yards for the school age component.

The facility will be sharing the yard with the Penngrove Elementary School children, licensee representative will submit a waiver request to share the yard with alternating schedules.

LPAs observed all classrooms to be clean, safe, sanitary, and in good repair. A comfortable temperature for children shall be maintained at all times. Furniture and equipment were observed to be maintained in good condition, free of sharp, loose or pointed parts. All materials and surfaces accessible to children, including toys, shall be free of toxic substances. All play equipment and materials used by children were observed to be age-appropriate. LPAs observed no fireplace or open face heaters. LPAs observed fully charged fire extinguisher, carbon monoxide and smoke detectors in the facility. There are 75 chairs, 14 tables, 19 toilets, 6 urinals, and 20 sinks for the school age children. Location of the bathrooms are the multipurpose room, the basement, bathrooms located by Classroom 4, bathrooms located by Classroom 2, bathrooms located by Classrooms 9, 10, and 11. Center director provided map of entire elementary school site. Staff have separate bathroom. Sick children will be isolated in the director’s area located in the basement. Sick children also have access to staff bathrooms. LPAs observed that items that may pose a danger to children were stored in a locked cabinet that is inaccessible to children. LPAs advised that applicant maintains first-aid supplies in a location accessible to staff but inaccessible to children.

As per center director, the meals that the facility are providing during the normal functioning school day are snacks that are district provided and during break camps, the facility will provide breakfast, lunch, and snack that are also district provided. Applicant was advised that full-day programs shall ensure that each child has a lunch and children shall be free to drink as they wish. Drinking water is readily available for the children via water fountains and brita pitchers.

Outdoor area for school age children were free of hazards including, holes, broken glass dry grasses, and other debris that pose a fire hazard. Shade was provided by building onnings. The areas around and under high climbing equipment, swings, slides and other similar equipment was observed to be cushioned with woodchips that can absorb a fall. The play yard is enclosed by a fence at least four feet high to protect children and to keep them in the outdoor activity area. Any construction or equipment that could pose a hazard in the outdoor activity area shall be made inaccessible to children in care. LPAs observed no bodies of water.


Report continued on LIC 809-C.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
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 AT PENNGROVE ELEMENTARY
FACILITY NUMBER: 493011058
VISIT DATE: 03/24/2026
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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 as specified in Health and Safety Code section 1597.16.

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).

LPAs referred center director to the Department website for lead: Lead Toxicity Prevention and Water Testing information (https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information)

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated 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

LPAs reviewed with applicant representative the LIC 311A, Records to Be Maintained at The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Applicant representative 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.

Applicant 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.

Report continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
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 AT PENNGROVE ELEMENTARY
FACILITY NUMBER: 493011058
VISIT DATE: 03/24/2026
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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.

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 inquires 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.

The following corrections are needed before a licensure will be considered:

1. Final review of application packet by LPM

2. Waiver request for usage of shared play yard with school program

3. Plan of operation for bathroom usage to avoid commingling of facility and elementary school children

4. Submission of updated LIC 200A with up to date hours of operation and age range for school age children

An exit interview was conducted with the above item discussed.

This report and appeal rights were provided to Christopher Sachen, Center Director.

Final license determination will be made upon review by the Licensing Program Manager.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
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