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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010057
Report Date: 11/12/2025
Date Signed: 11/12/2025 03:39:13 PM

Document Has Been Signed on 11/12/2025 03:39 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:		GOAD, DAVIDFACILITY TYPE:
840
ADDRESS:730 N WEBSTER STREETTELEPHONE:
(925) 457-7138
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 120TOTAL ENROLLED CHILDREN: 118CENSUS: 52DATE:
11/12/2025
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:David GoadTIME VISIT/
INSPECTION COMPLETED:
03:43 PM
NARRATIVE
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On 11/12/2025, Licensing Program Analyst (LPA), Robert Maciel made a case management inspection and met with director, David Goad. The inspection was made in response to water lead testing results received from the California State Water Resource Control Board. The test results showed that the following faucet(s) tested above the allowable level (5.5 ppb) of lead in the water: Sample Site, "S", located in room 23 had a reading of 7.0ppb. Any other sources of water that were tested measured below the allowable level of 5.5ppb.

The facility is based on the grounds of Valley Vista Public Waldorf School. Room 23 is not consistently used by the facility for childcare, only as an alternative location for activities. Director stated that room 23 is not currently being used by the facility and that the facility intends to discontinue use of the room, removing it from the licensed rooms that are shared with the Valley Vista Public Waldorf School but has not yet confirmed which action they will take to remediate the lead level exceedance for faucet S.

Director submitted the External Water Sampling Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276) and Facility Sketch/Floor Plan (LIC 999) to LPA.

The following deficiency is being cited (see LIC 809D). Appeal Rights was provided. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, David Goad
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2025
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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Document Has Been Signed on 11/12/2025 03:39 PM - It Cannot Be Edited


Created By: Robert Maciel On 11/12/2025 at 02:59 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: 11/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2025
Section Cited

101700.3(b)(2)

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Licensees shall maintain a lead value at or below the Action Level of 5.5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care.
This requirement was not met as evidenced by:
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The Director stated that the facility will not use room 23 until the faucet is replaced and retested with an allowable level of lead or the room is removed from the rooms licensed by the facility and will submit confirmation
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Based on results obtained from the California State Water Resource Control Board, faucet "S" in room 23 tested at a value above the allowable action level for lead content. Faucet “S” had a value of 7ppb, which exceeds the allowable value of 5.5ppb as defined in WD section 101700.3. This poses a potential health and safety risk to individuals in care.
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of which action the facility will take by 11/14/25, with the remediation completed and submitted to LPA by 12/10/25.

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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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Robert Maciel
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2025


LIC809 (FAS) - (06/04)
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