<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841007
Report Date: 06/11/2021
Date Signed: 06/11/2021 02:19:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KCE CHAMPIONS LLC @ WOODCREST ELEMENTARY SCHOOLFACILITY NUMBER:
334841007
ADMINISTRATOR:ANAHI ENRIQUEZFACILITY TYPE:
840
ADDRESS:16940 KRAMERIA AVENUETELEPHONE:
9517801215
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:35CENSUS: 0DATE:
06/11/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Keith Murray, Area ManagerTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A meeting was held at the Inland Empire Child Care Regional Office at the request of the area manager. Present for the meeting were Licensing Program Manager (LPM) Kimberly Williams, Licensing Program Analyst (LPA) Sharleen Robinson, Area Manager Keith Murray.

The meeting was held to discuss:


· Director Qualifications
· Designation of Responsibility
· Partnership with Community Care Licensing
· Reporting requirements
· Criminal Record Clearance
· Staff requirements

The area manager was reminded that each site is required to have a director. Each director is required to submit director requirements prior to working at the facility. All staff must be fingerprint cleared and associated to the facility prior to working at a facility. The area manager has agreed to submit and or update the following for each site:

· Update facility names for the site requiring name changes (LIC200A)
· Update facility hours for the sites requiring changes (LIC200A)
· Send director packets for each site:

1. Criminal Background Clearance Transfer Request (LIC 9182) or Copy of
completed Live Scan (LIC 9163) and a copy of Photo ID.
2. Copy of Official transcript to verify qualifications or Site Supervisor Permit
See LIC809C for the remainder of the report>>>>>>>>>>>>>>>>>>>>>>
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Sharleen RobinsonTELEPHONE: (951) 233-7183
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KCE CHAMPIONS LLC @ WOODCREST ELEMENTARY SCHOOL
FACILITY NUMBER: 334841007
VISIT DATE: 06/11/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
3. Copy of Verification of experience: Resume or LIC 501.
4. Copy of Health Screening Report and T.B. Clearance (LIC 503) completed no
more than a year prior to hire.
5. Proof of Immunizations against influenza, pertussis and measles
6. Copy of mandated reporter training certificate
7. Copies of EMSA approved 16-hour health and Safety Training Certificates:
Preventative Health, CPR & First Aid.
8. Lead training certificate.
9. Criminal Record Statement (LIC 508).
10. Designation of Administrative Responsibility (LIC 308) – Original Signed by
Licensee or CEO.
11. Evaluation of Director Qualifications (LIC 9096) – Original
12. New Personnel Summary to reflect staff changes (LIC 500). - Original
13. Updated Emergency Disaster Plan (LIC 610) – Original
14. AB 633 requires all new directors, within 90 days of hire, to attend the Child
Care Center Record Keeping Orientation either online or in our office.

The area manager will implement a process to have each employee carry their file with them from site to site. The area manager was provided with the following:
· LIC311A List of records to be maintained at the facility
· Lead poison facts
· Provider information notice PIN 21-08-CCLD
· Oversight role and resumption of on-site inspections
· LIC500 Personnel Report
· LIC200A application for child care center license
· LIC309 Administrative organization
· LIC308 Designation of facility responsibility
· LIC9182 Criminal Background Clearance Transfer Request
· LIC610 Emergency disaster Plan
· Guardian facts administrative organization
Quarterly updates: https://www.cdss.ca.gov/Portals/9/CCLD/Quarterly/210506%20CCP%20QU%20SUMMER%202021.pdf
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Sharleen RobinsonTELEPHONE: (951) 233-7183
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KCE CHAMPIONS LLC @ WOODCREST ELEMENTARY SCHOOL
FACILITY NUMBER: 334841007
VISIT DATE: 06/11/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPM Williams advised the area manager to conduct an in-service meeting by July 11, 2021. The Area manager agrees to send LPA Robinson a copy of the in-service meeting agenda.

The area manager agrees to submit the required staff qualifications and or facility update request to LPA Robinson by the due date of June 21, 2021.

An exit interview was conducted and a copy of this report was provided to the
The area manager.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Sharleen RobinsonTELEPHONE: (951) 233-7183
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3