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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406216356
Report Date: 08/12/2022
Date Signed: 08/16/2022 04:05:08 PM

Document Has Been Signed on 08/16/2022 04:05 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 @ CAPPY CULVERFACILITY NUMBER:
406216356
ADMINISTRATOR:TAMARA PAYNE-ALEXFACILITY TYPE:
840
ADDRESS:11011 HERITAGE LOOP ROADTELEPHONE:
(408) 348-1610
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 0DATE:
08/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Mahryka MirandaTIME COMPLETED:
02:46 PM
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THIS IS AN AMENDED REPORT FROM REPORT ISSUED ON 08/12/2022

On the August 12, 2022 at 1:10 PM, Licensing Program Analyst (LPA) Francisco Pedroza conducted an announced Prelicensing inspection. LPA met with Site Supervisor Mahryka Miranda and advised her the purpose of the inspection. Site Supervisor provided LPA a tour of the facility inside and out. There was no children in care at the time of the inspection.

Facility is located on a local school grounds. LPA observed the required licensing documents mounted on two boards within view of the public. The facility will be using three (3) classrooms for children in care. The facility will be using the multipurpose room mainly for children. The children will have access to the library and computer lab as well during care. The facility had enough restrooms for children inside and out. The facility will be providing one snack for children in care. Children will have access to books, tables to complete their homework, and other activities. Children will have access to the school blacktop with basketball courts, handball walls, and a large grass area with a playground structure. Water will be available for children inside and out.

LPA provided and reviewed with Site Supervisor the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted. LPA discussed information capacity, ratios, current Covid-19, and safe sleep requirements. Site Supervisor was made aware that it is the facility's responsibility to know the current regulations for a CCC which can be accessed on-line at www.cdss.ca.gov.

The center meets Title 22 Division 12 requirements.

Continued on 809-C
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisco Pedroza
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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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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 @ CAPPY CULVER
FACILITY NUMBER: 406216356
VISIT DATE: 08/12/2022
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License will be effective today, August 12, 2022 for 30 school-age children.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817.

Site Supervisor was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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.htm

Exit interview conducted and report was reviewed with the Site Supervisor.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Francisco Pedroza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
LIC809 (FAS) - (06/04)
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