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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215479
Report Date: 05/02/2025
Date Signed: 05/02/2025 12:34:35 PM

Document Has Been Signed on 05/02/2025 12:34 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 GABRIEL PSFACILITY NUMBER:
406215479
ADMINISTRATOR/
DIRECTOR:		TAMARA PAYNE-ALEXFACILITY TYPE:
850
ADDRESS:8500 SAN GABRIEL ROADTELEPHONE:
(805) 952-5083
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 23TOTAL ENROLLED CHILDREN: 23CENSUS: 4DATE:
05/02/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Holly HivelyTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 5/2/25, at 11:25 AM, Licensing Program Analyst (LPA) Matthew Sapien conducted an unannounced annual random Inspection of 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. The LPA, in the company of the Director, toured the interior and exterior of the CCC. The CCC operates out of a modular classroom (classroom 1006) and is on the grounds of San Gabriel Elementary School. The CCC utilizes the aforementioned classroom, a black top, and school restrooms.

The CCC's hours of operation are 7:00 AM until 6:00 PM Monday through Friday. During the inspection, LPA observed 4 children in care along with 2 additional staff members who are cleared and associated.

The classroom of the CCC is clean and orderly. The classroom has age-appropriate books, equipment, and other furnishings for children in care. The classroom contains a number of closets, cabinets, and other storage containers for childcare equipment, files, and other related items. The bathroom, located on school grounds, possesses 2 sinks and 3 toilets (with one being wheelchair accessible), and was clean and orderly.

The CCC possesses an operational refrigerator that has food items for children and staff. The CCC provides two snacks for children in care. Lunches are brought from home by children. There is available drinking water for children at the CCC via a 5-gallon water dispenser. Site Supervisor informed LPA that children bring reusable water bottles from home to drink with. Children are also supplied with cups to drink with if needed.

CCCs constructed before 1/1/20, are supposed to test their water (used for drinking and food preparation) for lead contamination before 1/1/23, and then every 5-years except after the date of the first test. For child care center licenses issued after 7/1/22, the licensee shall test their water for lead within 180 days of (CONT. LIC 809-C, Page 2)

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Matthew Sapien
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
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 PS
FACILITY NUMBER: 406215479
VISIT DATE: 05/02/2025
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of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). Through interview and record review, LPA verified that a lead testing was completed in accordance to the directives outlined above. Lead testing was conducted and completed in late June of 2023.

LPA observed snack menus, required notices, and other relevant licensing documents posted prominently within the classroom of the CCC. LPA also reviewed the children's sign in and sign out forms in each of the classrooms and found the arrival times of children, along with spaces for departure times. The signatures of authorized representatives were also present.

LPA observed a carbon monoxide detector in the classroom. A detector was tested at 10:20 AM and was found to be operational. In the classroom, cleaning compounds and a lock box for medication are stored in elevated kitchen cabinets. Sharps, like scissors, were observed in a locked drawer in the teacher’s desk. LPA also observed a First Aid kit backpack in the CCC that contains hydrogen peroxide, band aids, and other appropriate supplies.

The outdoor playground area is enclosed by chain linked fencing throughout. The fence’s entry and exit gates are secure and furnishings in the area are age appropriate. Again, just the blacktop outside of the modular classroom is available for children. Shade is provided by neighboring building overhangs. Site Supervisor attested that children are always supervised while outside and that the outdoor area is inspected prior to letting children outside.

A sampling of staff and children's records were reviewed. The children’s records were complete and were found to contain emergency contact information as well admission agreements, among other relevant licensing documents and forms. Staff records were reviewed and contained current pediatric CPR and First Aid certifications (EMSA approved) and Mandated Reporter Training certificates among other relevant licensing documents. The last disaster drill on site occurred on 5/1/ 25. LPA reminded Site Supervisor that disaster drills are required every six months by the Department. LPA confirmed that there are no bodies of water, firearms, or ammunition that are stored on site.

This facility does not currently provide Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 and link to publication Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/. (CONT. 809-C, Page 3)

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

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: KCE CHAMPIONS LLC @ SAN GABRIEL PS
FACILITY NUMBER: 406215479
VISIT DATE: 05/02/2025
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Facility representative was reminded that all adults 18 and over, including employees and volunteers, as specified in HSC 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.

Facility representative was informed of the MyChildCarePlan.org website; 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.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

During today's visit, no deficiencies were issued.

Facility Representative was provided with Appeal Rights (LIC 9058) and a Notice of Site Visit (LIC 9213). Notice of Site Visit must be posted for 30 days or a civil penalty of $100 may apply.

An exit interview was conducted and report as reviewed with Facility Representative, Holly Hively.

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

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
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