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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010057
Report Date: 01/24/2025
Date Signed: 01/24/2025 02:52:07 PM

Document Has Been Signed on 01/24/2025 02:52 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KCE CHAMPIONS LLC @ VALLEY VISTAFACILITY NUMBER:
493010057
ADMINISTRATOR/
DIRECTOR:		JUNIOR, TIFFANYFACILITY TYPE:
840
ADDRESS:730 N WEBSTER STREETTELEPHONE:
(925) 457-7138
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 120TOTAL ENROLLED CHILDREN: 45CENSUS: 0DATE:
01/24/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:52 AM
MET WITH:Taylor RamaliaTIME VISIT/
INSPECTION COMPLETED:
03:01 PM
NARRATIVE
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A case management visit was made to the facility today by Licensing Program Analyst (LPA) Robert Maciel for the purpose of obtaining a packet of required documents for the Director, Taylor Ramalia (D1).

During a plan of correction visit on 12/12/24, LPA requested D1 submit a director's packet to the department by 12/22/24.

During today's visit, LPA observed no children in care. LPA reviewed the staff file for D1 which revealed that D1 did not possess a preventative health practices certificate, a complete LIC503 Health Screening, proof of immunity against Pertussis, and verification of past work experience.

D1 stated that no other staff possess a preventative health certificate. D1 stated that she began working on 12/2/24.

The following violations of the California Code of Regulations (Title 22) were cited during today's inspection (see LIC809-D). Appeal rights were provided. Exit interview and report was read with the Director, Taylor Ramalia. A notice of site visit was given and must remain posted for 30 days. Failure to do so shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/24/2025 02:52 PM - It Cannot Be Edited


Created By: Robert Maciel On 01/24/2025 at 01:49 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KCE CHAMPIONS LLC @ VALLEY VISTA
FACILITY NUMBER: 493010057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2025
Section Cited
CCR
101212(b)

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The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

This requirement was not met as evidenced by:
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Director stated she would submit a written statement attesting to her understanding of the reporting requirements to LPA by email at robert.maciel@dss.ca.gov.
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Based on record review and interview, the Director (D1) was not reported to the department after starting on 12/02/24 which poses a potential risk to the health and safety of persons in care.
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Type B
02/21/2025
Section Cited
CCR101215.1(m)

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A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866.

This requirement was not met as evidenced by:
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Director stated she will sign up for a preventative health training course through 4C's and submit a copy of the preventative health certificate to LPA by email at robert.maciel@dss.ca.gov.
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Based on interview and record review, no current employee at the facility possesses a current preventative health training certificate which poses a potential risk to the health and safety of persons 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:Erin Virrueta
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/24/2025 02:52 PM - It Cannot Be Edited


Created By: Robert Maciel On 01/24/2025 at 02:03 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KCE CHAMPIONS LLC @ VALLEY VISTA
FACILITY NUMBER: 493010057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2025
Section Cited
CCR
101216(g)(1)

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Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement was not met as evidenced by:
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Director stated that she would obtain a complete LIC503 Health Screening and submit a copy of the form to LPA by email at robert.maciel@dss.ca.gov.
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Based on record review, the director (D1) did not possess a complete LIC503 Health Screening which poses a potential risk to the health and safety of persons in care.
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Type B
02/21/2025
Section Cited
HSC1596.7995(c)

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The day care center shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the day care center.

This requirement was not met as evidenced by:
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Director stated she would obtain proof of immunization against pertussis and send a copy to LPA by email at robert.maciel@dss.ca.gov.
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Based on record review, the director (D1) did not possess proof of immunization against pertussis which poses a potential risk to the health and safety of persons 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:Erin Virrueta
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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