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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010058
Report Date: 12/12/2024
Date Signed: 12/12/2024 02:50:51 PM

Document Has Been Signed on 12/12/2024 02:50 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: 120TOTAL ENROLLED CHILDREN: 170CENSUS: 0DATE:
12/12/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:28 PM
MET WITH:Mikayla SpainTIME VISIT/
INSPECTION COMPLETED:
03:02 PM
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Licensing Program Analyst (LPA), Robert Maciel made an unannounced Plan of Correction (POC) visit and met with Director, Mikayla Spain (S1), for the purpose of following up on an outstanding POC that was due by 02/12/2024. During the annual inspection on 1/12/2024, the facility was cited for staff 2 (S2), staff 3 (S3), staff 4 (S4), staff 5 (S5), staff 6 (S6), staff 8 (S8), staff 10 (S10), staff 11 (S11), staff 13 (S13), and staff 15 (S15) missing a complete LIC503 Health Screening.

During today's visit, LPA observed no children in care. LPA requested facility records and reviewed staff files. LPA observed complete LIC503 Health Screenings for S2, S3, S5, S6, S8, S10, and S13. Director stated that S4, S11, and S15 no longer work at the facility. LPA gave Letter of Deficiency Citations Cleared to Director.

No deficiencies were cited during today's visit. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, Mikayla Spain.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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