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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206847
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:52:46 PM

Document Has Been Signed on 10/19/2023 04:52 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 BENITOFACILITY NUMBER:
406206847
ADMINISTRATOR:DAWN MARTINFACILITY TYPE:
840
ADDRESS:4300 SAN BENITOTELEPHONE:
(805) 975-6105
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 58TOTAL ENROLLED CHILDREN: 58CENSUS: 24DATE:
10/19/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
04:06 PM
MET WITH:Kristin ElliotTIME COMPLETED:
05:00 PM
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On 10/19/23, Licensing Program Analyst (LPA) Elvin Baddley conducted an unannounced Case Management Inspection of the abovementioned Child Care Center (CCC) to assess a request for the use of an outdoor play area. LPA met with Kristin Elliot, Site Supervisor of the CCC, and explained the nature and purpose of the inspection. LPA notes 24 children are on site along with 3 teachers providing care and supervision. LPA notes Site Supervisor is assisting with the care and supervision of children in care.

The CCC is on the grounds of San Benito Elementary School. Site Supervisor has obtained permission from the Elementary School's administration to use the kindergarten's play yard at the conclusion of the school day. As such, CCC children will not commingle with elementary school students when using the outdoor play yard.

LPA observed the play yard to have age appropriate play structures and cushioning material to absorb falls. The area is enclosed and within 20 yard of the CCC's classroom and restrooms.

LPA has received an undated LIC 999 noting the play yard as well as a formal request to use the play yard.
In view of the aforementioned, the CCC is granted permission to use the school's kindergarten yard as a supplemental outdoor play area in addition to the preexisting outdoor spaces/yards.

No deficiencies were cited during today's inspection and LPA forwarded a Notice of Site Visit which is to be posted as required by H&S Code Section 1596.817. The Notice of Site Visit must remain posted for 30 days or a civil penalty $100.00 may apply.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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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