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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343609384
Report Date: 07/11/2023
Date Signed: 07/11/2023 01:05:07 PM


Document Has Been Signed on 07/11/2023 01:05 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CHAMPIONS @ EDNA BATEY ELEMENTARYFACILITY NUMBER:
343609384
ADMINISTRATOR:KIM BRASSYFACILITY TYPE:
840
ADDRESS:9421 STONEBROOK DRIVETELEPHONE:
(916) 714-0110
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:93CENSUS: 23DATE:
07/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cibely InzunzaTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Jennie Tedlos and Licensing Program Manager (LPM) Bettina Engelman conducted a case management inspection to deliver an Immediate Exclusion Order. The employee being served is Izanicque Burnett.

Licensing staff did not observe Ms. Burnett to be present at the facility today. Facility Representative, Cibely Inzunza, stated that this Champion's location on Stonebrook Drive, License #343609384, has never had an employee or volunteer named Izanicque Burnett.

Today, the Facility Representative, Cibely Inzunza, was advised and understands that the individual listed above cannot be present at this facility or at any Champions facilities.

An exit interview was conducted with today's Facility Representative.

LPA reviewed report with the Facility Representative, Cibely Inzunza, and provided copies of the report along with Appeal Rights. A notice of site visit was provided and posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.


No Title 22 Deficiencies were cited during the visit.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 215-3003
LICENSING EVALUATOR NAME: Jennie TedlosTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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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