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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215807
Report Date: 08/26/2021
Date Signed: 08/26/2021 10:45:26 PM

Document Has Been Signed on 08/26/2021 10:45 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 @ VINEYARD ELEMENTARYFACILITY NUMBER:
406215807
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:2121 VINEYARD DRIVETELEPHONE:
(408) 348-1610
CITY:TEMPLETONSTATE: CAZIP CODE:
93465
CAPACITY: 31TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:09 PM
MET WITH:Stepanie Huerta TIME COMPLETED:
05:50 PM
NARRATIVE
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On August 26, 2021 at 4:00 PM, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Required Annual inspection of the above mentioned Child Care Center (CCC). Prior to inspection, LPA asked pre screening questions related to COVID 19, Site Supervisor's responses indicate there was no COVID 19 exposure on site. LPA met with Site Supervisor Stephanie Huerta and Assistant, Jill Allen and explained the nature of the inspection. Center is located at Vineyard Elementary School using classroom no. D1. There were 12 children present during the inspection.

LPA in the company of Site Supervisor conducted the physical plant tour. LPA observed the following, classroom is adequately equipped with age and size appropriate furniture and equipment. Water cooler supplies drinking water in the classroom. Smoke and carbon monoxide detectors were observed in the classroom. School playground is used for outdoor activities. Outdoor activity area is supplied with age and size appropriate equipment. An adequate amount of cushioning material, wood chips are in place under play equipment. Drinking water is provided in the outdoor play area by a water cooler. Required licensing forms are posted by the entrance door. Center implements California Department of Public Health Guidance for Child Care Programs.

A sampling of staff and children records were reviewed. The children’s records were complete and contain emergency contact information. A review of staff records on 8/26/2021 indicates that all facility staff have criminal record clearance.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: KCE CHAMPIONS LLC @ VINEYARD ELEMENTARY
FACILITY NUMBER: 406215807
VISIT DATE: 08/26/2021
NARRATIVE
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CPR and First Aid expired on 8/2/2021. Sign in and sign out record meets the regulation requirements. Site Supervisor educational qualification was verified. Immunization record was on file.

Site Supervisor noted no firearms or ammunition is stored on site.

Incidental Medical Services (IMS) policy was discussed. 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.htmhttp://www.ada.gov/childqanda.htm

In areas evaluated, deficiency was cited under Title 22 Division 12 of California Code of Regulations. Appeal Rights were provided and explained.



Exit interview was conducted with Site Supervisor, Stephanie Huerta. THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL BE ASSESSED.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Gigi Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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Document Has Been Signed on 08/26/2021 10:45 PM - It Cannot Be Edited


Created By: Gigi Reyes On 08/26/2021 at 05:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: KCE CHAMPIONS LLC @ VINEYARD ELEMENTARY
FACILITY NUMBER: 406215807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited
CCR
101216(f)

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(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.
This requirement is not met as evidenced by :
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Site Supervisor will submit proof of Pediatric CPR and First Aid TrainingCertificate no later than 9/17/2021 to CCLD.
gigi.reyes@dss.ca.gov
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During file review, it was observed that CPR and First Aid expired on 8/2/2021. This poses a potential risk to health and safety of children in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Maria Mueller
LICENSING EVALUATOR NAME:Gigi Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


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