343624351-11-7-2022-03-CC-ASUR-CKXPR7-20221107103217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624351
Report Date: 11/07/2022
Date Signed: 11/07/2022 10:32:27 AM

Document Has Been Signed on 11/07/2022 10:32 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	KCE CHAMPIONS LLC @ CRES		FACILITY NUMBER:	343624351
ADMINISTRATOR:	AMY DODGE		FACILITY TYPE:	850
ADDRESS:	13580 JACKSON ROAD		TELEPHONE:	(530) 391-6816
CITY:	SLOUGHOUSE	STATE: CA	ZIP CODE:	95683
CAPACITY: 15	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	11/07/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Amy Dodge		TIME COMPLETED:	10:45 AM

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Licensing Program Analyst (LPA) Amanda Sutter met with Licensee Representative Amy Dodge for the purpose of an announced pre-licensing inspection. Staff Camille Gordon was also present. Applicant requests a preschool license to serve 15 preschool children from age two to entry into kindergarten. The program will operate Monday through Friday from 7:00 AM to 5:30. The fire clearance was granted on 8/5/2022.

Applicant acknowledges that the following documents must be posted at all times: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, Effects of Lead Exposure, car seat poster, menus, and daily schedule. LPA provided and discussed LIC311A and the forms that must be in each child's and each staff member's file. The facility will provide AM and PM snack.

INDOOR ACTIVITY SPACE:
There is one classroom. LPA observed a sufficient number of chairs, tables, cubbies, and napping cots for 15 preschool children. LPA observed a variety of age-appropriate toys and equipment. There is a first aid kit in the classroom cupboard. Medications will be stored in a locked cupboard in the classroom. LPA observed cleaning disinfectants are appropriately stored and inaccessible to children. Applicant stated there are no poisons or firearms on the premises. Applicant stated that the facility plans to use a large jug of water and personal water bottles both in the classroom and on the playground. LPA observed a functional carbon monoxide detector. LPA observed a paper sign-in/sign-out system.

LPA measured one classroom. The total classroom space contains a total of 816.2708 square feet, which accommodates Applicant's request for 15 preschool children. There are 4 toilets and 3 sinks for the children, and a separate private restroom for the staff. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the office area and will use the staff restroom, if necessary.
Report continues on 809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: KCE CHAMPIONS LLC @ CRES	FACILITY NUMBER: 343624351
	VISIT DATE: 11/07/2022

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OUTDOOR ACTIVITY SPACE:
There is one outdoor area on the property for preschool children. The outdoor play area is fenced with a wrought iron fence that is four feet tall. The center plans to use the same playground for the preschool and School Age component and will submit a Shared Outdoor Space waiver along with a rotating schedule. LPA observed a variety of age-appropriate outdoor toys and equipment. The play structure includes a safety label, which designates use for children 5 to 12 years old. Staff understands that they will need to ensure that they are following the structure's manufacturing information and that children younger than 5 years old should not be allowed to use the structure. LPA observed bark beneath the structure and that there is enough cushioning material to absorb any falls. There are no bodies of water on the premises. There are shaded areas supplied by trees and overhangs.

LPA measured the outdoor activity space. The outdoor play area contains a total of 10807 square feet, which accommodates Applicant's request for 15 preschool children. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

The facility's Plan of Operation is located in the preschool file. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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)/(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.

LPA 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. LPA 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.

Report continues on 809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: KCE CHAMPIONS LLC @ CRES	FACILITY NUMBER: 343624351
	VISIT DATE: 11/07/2022

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This facility evaluation report was reviewed and discussed with Licensee Representative. Licensee Representative was encouraged to the visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers.

The following items are required before a license will be issued:

1. Licensing Program Manager’s final file review.

2. Proof of required postings.

3. Proof room is set up and ready for operation.

4. Submit insufficient outdoor waiver with a rotating schedule.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC809 (FAS) - (06/04)

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