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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 313621215
Report Date: 03/11/2022
Date Signed: 03/11/2022 07:50:24 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2022 and conducted by Evaluator Katrina Owens
COMPLAINT CONTROL NUMBER: 03-CC-20220304144708
FACILITY NAME:KCE CHAMPIONS LLC @ JOHN ADAMS ACADEMYFACILITY NUMBER:
313621215
ADMINISTRATOR:KAREN RINGUEFACILITY TYPE:
840
ADDRESS:1 SIERRA GATE PLAZATELEPHONE:
(916) 462-2573
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:75CENSUS: 5DATE:
03/11/2022
UNANNOUNCEDTIME BEGAN:
06:30 AM
MET WITH:Andrew Pipkin - School -age TeacherTIME COMPLETED:
08:00 AM
ALLEGATION(S):
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PERSONA LRIGHTS: Day care child is assulting day care children.
INVESTIGATION FINDINGS:
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An unannounced inspection was conducted by Licensing Program Analyst Owens. LPA Owens met with School-age Teacher, Andrew Pipkin. Present at time of inspection were 3 day care children then 2 additional children arrived a short time later.

The purpose of the inspection is to open and close a complaint investigation. Interviews were conducted at time of inspection.

Based on interviews a child at the facility has been aggressive with other children on several occasions; behavior includes pushing, hitting and spitting other children. The preponderance of evidence standard has been met during this investigation, therefore the above allegation is found to be SUBSTANTIATED.

Violations of the California Code of Regulations, Title 22, Division 12 & Chapter 3 are being cited on the attached LIC 9099-D.

Notice of site visit posted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 03-CC-20220304144708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: KCE CHAMPIONS LLC @ JOHN ADAMS ACADEMY
FACILITY NUMBER: 313621215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
CCR
101223(a)(3)
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PERSONAL RIGHTS:
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Staff stated the facility has addressed issue by informing parent that child needs one on one shadowing and cannot attend facility until this recommendation is in place.
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This requirement is not met as evidence by interviews indicate there is a child at the facility that has used aggressive behavior toward other children on several occasions.
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Staff will email schedule showing child is not attending the facility.
He will submit on or before 3/18/2022.
A civil penalty may be accessed if POC is not received on or before 3/18/2022.
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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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2