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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313625947
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:46:25 PM

Document Has Been Signed on 08/14/2024 01:46 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KCE CHAMPIONS LLC @ EV CAINFACILITY NUMBER:
313625947
ADMINISTRATOR/
DIRECTOR:		BRITTANY TOROKFACILITY TYPE:
860
ADDRESS:150 PALM AVETELEPHONE:
(530) 269-9126
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 0DATE:
08/14/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Brittany TorokTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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During today's visit, Centralized Application Bureau (CAB) Licensing Program Analyst (LPA) Arianna Manabat met with the Site Supervisor Brittany Torok for the purpose of an announced change of location pre-licensing inspection from the previous license (KCE - Skyridge [313625081]) to the EV Cain elementary school. Applicant is requesting to serve 60 elementary school children ages enrolled and attending transitional kindergarten to 14 years of age during the hours of Monday through Friday 6:30am - 6:00pm. The rooms are located in portables 33 and 31. The facility is located on the EV Cain Elementary school campus.

The facility's policy for food service is that parents/guardians will be providing lunch to their children and that the morning and afternoon snacks are going to be provided via the facility. During the summer the facility provides lunch. Additionally, LPA Manabat reviewed with applicant the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

INDOOR ACTIVITY SPACE:
There are 2 classrooms on site that are used for the facility, #33 and #31. LPA Manabat observed that there are appropriate supplies currently displayed in each classroom. The facility representative was reminded that any items that need to have teacher supervision, such as age appropriate scissors, should be stored inaccessible to children until ready to use. There are first aid kits located in each classroom. Any medications will also be stored inaccessible to children. The facility representative stated that medications that need to be refrigerated will stored in the staff refrigerator with a lock on the door. LPA Manabat observed cleaning disinfectants are appropriately stored and inaccessible to children in the locked cabinet.

Report continues on LIC809-C
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KCE CHAMPIONS LLC @ EV CAIN
FACILITY NUMBER: 313625947
VISIT DATE: 08/14/2024
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The Applicant stated there are no poisons, bodies of water, or firearms on the premises. LPA Manabat discussed the importance of storing any poisons in a locked area with either a combination or a key lock.
LPA observed a functional carbon monoxide detector and fire extinguisher. LPA discussed the sign-in/sign-out sheet system and the applicant stated that this will be using a paper sign in and sign out system. Water will be provided to the classroom via filtered water dispensers and outdoor water fountains.

INDOOR MEASUREMENTS:
CAB LPA did not measure the indoor space as per Title 22 regulation Indoor Activity Space for School-Age Children 101538.3(c) which states that School-age child care programs that meet the requirements of Health and Safety Code Section 1596.806 are exempt from square-footage requirements for indoor activity space.
There are currently 6 toilets and 6 sinks available for use for and an exclusive bathroom only for staff members that is located adjacent to the children's restrooms. Children who become ill during the day will be isolated in the cozy area in room #31 with a staff member. There will be a mat available in this space.

OUTDOOR ACTIVITY SPACE:
There is one fenced outdoor activity play space on the property available for children's use. The outdoor play areas are fenced with a chain-linked fence that is at least four feet tall. There are no play structures built on the playground currently but the site supervisor stated that they are planning to install a structure and would notify licensing when the structure is built. LPA Manabat did not measure the outdoor space as per Title 22 regulation 101538.2 (c) for Outdoor Activity Space for School-Age Children states that School-age child care programs that meet the requirements of Health and Safety Code Section 1596.806 are exempt from square-footage requirements for outdoor activity space.

Shade is provided via overhangs and sides of the building. Water is provided via water fountains outside of the portables. There is a sufficient amount of equipment and toys available for children's use.

Report continues on LIC809-C.
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KCE CHAMPIONS LLC @ EV CAIN
FACILITY NUMBER: 313625947
VISIT DATE: 08/14/2024
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (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 discussed the following: 100% supervision is required at all times, including in the bathroom; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. LPAs discussed with Applicant any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

Applicant 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.

Applicant 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 platform. 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.
Report continues on LIC809-C
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KCE CHAMPIONS LLC @ EV CAIN
FACILITY NUMBER: 313625947
VISIT DATE: 08/14/2024
NARRATIVE
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The following items are required before a license will be issued:

1. Manager approval

Exit interview conducted and report was reviewed with the Licensee Representative. The facility representative understands and acknowledges that any advertising for the facility should include their facility (license) number.
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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