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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206845
Report Date: 04/26/2023
Date Signed: 05/03/2023 02:11:48 PM

Document Has Been Signed on 05/03/2023 02:11 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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:KCE CHAMPIONS LLC @ SAN GABRIELFACILITY NUMBER:
406206845
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:8500 SAN GABRIELTELEPHONE:
(805) 975-8429
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 26DATE:
04/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:01 PM
MET WITH:Deri KayeTIME COMPLETED:
06:00 PM
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On 4/26/23, at 3:31 PM, Licensing Program Analysts (LPAs) Elvin Baddley and Dixie Wright conducted an unannounced Case Management at the abovementioned Child Care Center (CCC) to address an incident received by the Department on 4/21/23. The incident involved a child in care, herein C1, climbing onto an art cart and the art cart subsequently falling on top of C1, which resulted in C1 fracturing the right arm. LPAs met with Deri Kaye, Site Supervisor of the CCC and explained the purpose of the inspection. LPAs, in the company of Site Supervisor, toured the interior and exterior of the CCC. LPAs observed 26 children in the CCC along with four teachers (cleared and associated) providing care and supervision.

Site Supervisor informed LPAs the art cart was repositioned in the classroom and now is against the room's wall. The art cart is affixed to the wall by screw. In addition to affixing the art cart to the wall, the wheels of the art cart were removed.

Site Supervisor informed LPA C1 was returned to the CCC following the incident in a arm cast. C1 is reported to have no long lasting effects related to the incident.

The incident is reported to have occurred as a staff members was wiping a table and C1 attempted to climb the art cart to peer on the other side of the art cart. The staff member was unable to redirect C1 before the art cart fell.

LPAs and Site Supervisor discussed the location of the art cart, staff positioning as well as the activities of children in the interior of the CCC.

Given the LPAs' observations, along with interviews and record reviews, it is determined the actions of CCC staff did not contribute to the incident or C1's injuries. Further, CCC staff acted in accordance with Title 22 regulations.

No deficiencies were cited during todays inspection.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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