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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010058
Report Date: 05/09/2024
Date Signed: 05/09/2024 12:57:01 PM

Document Has Been Signed on 05/09/2024 12:57 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 @ MARY COLLINSFACILITY NUMBER:
493010058
ADMINISTRATOR/
DIRECTOR:		MIKAYLA SPAINFACILITY TYPE:
840
ADDRESS:1001 CHERRY STREETTELEPHONE:
(707) 364-6229
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 90DATE:
05/09/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Mikayla SpainTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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An increase of capacity prelicensing inspection was conducted May 9, 2024 at 11am by Licensing Program Analyst (LPA), Snow to increase the capacity for School Age children. LPA Snow met with facility representative Mikayla Spain/director of KCE Champions LLC @ Marry Collins to conduct an inspection of the Mary Collins school age program before and after school program. The program is currently licensed in Portable #1, Portable #2, & TK#1, today we are adding TK#2.

The facility has requested an increase from 90 to 120 school aged children, age 4-12 years. Fire clearance was approved on 3/14/24. Hours and days of operation M-F 7am to 820am before school & 130pm -6pm after school (early day Wednesday starts 12:45). They are open through most school holidays & summer. The facility is on the Mary Collins Elementary school grounds. This program meets Health and Safety Code 1596.806(a)(1 & 2), (b), (b)(1) and (d) and is therefore exempt from the toilet, interior and exterior activity square footage and outdoor fencing requirement. All 4 classrooms have attached bathrooms as follows: Portable #1 (1 toilet, 3 sinks), Portable #2 (1 toilet, 3 sinks) , & TK#1(1 t, 3 sink) & TK#2 (1 t, 3 sink & staff bathroom).

The indoor and outdoor activity spaces were toured, and the facility sketch was verified. No areas will be off limits to children. They use the elementary school play yards. The isolation area for sick children will be located in the office. There is safe and age-appropriate furniture, toys, and play equipment available for children. There is no pool, spa, pond, fountain, or any other body of water on the premises The poisons are locked in locking cabinets in each room. Director, Mikayla Spain said there are no weapons on property. Snacks are prepared am and pm in the classrooms and hot breakfast is available from the school cafeteria. Continued on next page
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KCE CHAMPIONS LLC @ MARY COLLINS
FACILITY NUMBER: 493010058
VISIT DATE: 05/09/2024
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Facility, Director, Mikayla Spain 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, except as specified in Health and Safety Code 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.

This facility previously submitted a plan to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) tollfree ADA Information Line at (800) 514-0301 (voice) or (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. LPA reviewed with facility Director, Mikayla Spain 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 the safe sleep regulations with Mikayla Spain facility representative and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource.
LPA also informed facility director, Mikayla Spain of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Representative, Mikayla Spain was informed of the MyChildCarePlan.org site, 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.
Continued on next page
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KCE CHAMPIONS LLC @ MARY COLLINS
FACILITY NUMBER: 493010058
VISIT DATE: 05/09/2024
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

The following is required before a license will be increased: Application (LIC 200A)
Administrative Organization (LIC 309)
Personnel Report (LIC 500)
Emergency Care and Disaster Plan (LIC 610) -need a separate one for each building& updated temporary relocations
Facility Sketch (LIC 999)
List of Furniture & Equipment (enough chairs, tables and toys for 120 capacity)
Director mandated reporter and first aid (verified current)
Additional documents & managerial approval will be required after a full file review.
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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