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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206845
Report Date: 07/30/2025
Date Signed: 07/30/2025 02:41:40 PM

Document Has Been Signed on 07/30/2025 02:41 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 BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:KCE CHAMPIONS LLC @ SAN GABRIELFACILITY NUMBER:
406206845
ADMINISTRATOR/
DIRECTOR:		TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:8500 SAN GABRIELTELEPHONE:
(805) 975-8429
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 28DATE:
07/30/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Holley HivelyTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 7/30/25, at 1:50 PM, Licensing Program Analyst (LPA) Matthew Sapien made an unannounced Case Management inspection at the abovementioned Child Care Center (CCC). LPA met with Holly Hively, Site Supervisor of the CCC and explained the nature and purpose of the inspection. LPA, in the company of the Site Supervisor, toured the interior and exterior of the CCC. At the time of the inspection, LPA observed 28 children in care. In addition to the Site Supervisor of the CCC, LPA also observed 7 additional staff members at the time of the inspection.

This Case Management inspection follows an Unusual Incident at the CCC which occurred on 7/15/25. On the following day of the incident, 7/16/25, it was reported to the Department. Importantly to note, the CCC's current hours of operation are 7:00 AM until 6:00 PM Monday through Friday.

During the incident, a child in care was using spinning monkey bars on the outdoor playground. While playing, the child fell off the spinning monkey bars and tried to brace themselves before hitting the ground. Because of the fall, the child landed directly on their left arm. CCC staff immediately gave the child ice packs to help with the pain and immediate swelling. The CCC also notified the parents of said child and the child was picked up and taken to the nearby hospital. The following day of the incident, 7/16/25, the staff contacted the parents who informed staff that the child fractured a bone near the elbow, is currently in a soft cast, and will eventually be put into a hard cast. Facility Representative informed LPA that the child returned to the CCC on 7/22/25. At the time of this inspection, the child was present and observed in a hard cast.

During today's visit, 7/30/25, the LPA viewed the facility with an emphasis on the playground and the spinning monkey bars that child fell from. LPA observed the monkey bars to be age appropriate (ages 5-12) for the injured child and the cushioning (wood chips) to be adequate for children in care. LPA reminded the Facility (CONT. 809-C, Page 2).

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2025
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 BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: KCE CHAMPIONS LLC @ SAN GABRIEL
FACILITY NUMBER: 406206845
VISIT DATE: 07/30/2025
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Representative of the importance of direct supervision over children in care and to ensure each child in care uses age appropriate equipment and structures at all times.

Facility Representative was provided a copy of their Appeal Rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Facility Representative, Holly Hively. Facility Representative was provided with a Notice of Site Visit (LIC 9213). The Notice of Site Visit form must be posted for 30 days or a civil penalty of $100 may apply.

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC809 (FAS) - (06/04)
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