406206847-9-28-2026-17-CC-MSAN-DYCQYN-20260928123525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 406206847
Report Date: 09/28/2026
Date Signed: 09/28/2026 12:35:38 PM

Document Has Been Signed on 09/28/2026 12:35 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 BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	KCE CHAMPIONS LLC @ SAN BENITO		FACILITY NUMBER:	406206847
ADMINISTRATOR/ DIRECTOR:	DAWN MARTIN		FACILITY TYPE:	840
ADDRESS:	4300 SAN BENITO		TELEPHONE:	(805) 975-6105
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 58	TOTAL ENROLLED CHILDREN: 58	CENSUS: 9	DATE:	09/28/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Tyler Maretti		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE

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On 9/28/26, at 12:00 PM, Licensing Program Analyst (LPA) Matthew Sapien made an unannounced case management (incident) inspection at the abovementioned Child Care Center (CCC). LPA met with Tyler Maretti, Facility Representative of the CCC, and explained the purpose of the inspection. LPA, in the company of the Facility Representative, toured the CCC throughout its entirety. At the time of the inspection, LPA observed 9 children in care. In addition to the Facility Representative of the CCC, LPA also observed 3 other staff members present on site (cleared and associated). The CCC is on the grounds of San Benito Elementary School.

This Case Management inspection follows an Unusual Incident at the CCC which occurred on 9/24/26. The incident was reported to the Department on 9/25/26 through a telephone call. Important to note, the CCC’s hours of operation are Monday through Friday ranging from 7:00 AM until 8:00 AM, 8:05 AM until 11:15 AM, 11:40 AM until 2:30 PM, and 2:30 PM until 6:00 PM.

Regarding the incident on 9/24/26, while utilizing a walking platform structure in the playground, C1 tried moving across the structure, lost their balance, slipped, and fell approximately six to eight feet to the ground. C1 fell directly onto the right arm. Important to note, the footing of the playground is made up of wood chips. Following the fall, C1 was consoled by staff and was given an ice pack right away. Child was soon picked up from the CCC by an authorized representative. A fracture diagnosis was given to the CCC on 9/25/26. The child has not returned to school since following the incident and an expected timeline for return at this time is unclear.

During today's visit, 9/28/26, the LPA had an in-depth conversation with the Facility Representative pertaining to the UIR and observed the playground area where the incident took place. LPA verified that the play structure was age appropriate for children in care, the surface had adequate cushioning, and that staff were positioned in appropriate areas during the incident. LPA reminded the Facility Representative of active supervision over children in care at all times.

During today's inspection, no citations were given. Facility Representative was provided a copy of their Appeal Rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Facility Representative, Tyler Maretti. Facility Representative was provided with a Notice of Site Visit (LIC 9213). Notice of Site Visit form must be posted for 30 days or a civil penalty of $100 may apply.

Maria Mueller
Matthew Sapien
	DATE: 09/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2026

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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