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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343612109
Report Date: 03/14/2022
Date Signed: 03/14/2022 05:44:40 PM



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
12/10/2021 and conducted by Evaluator Aruna Sridharan
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20211210093437
FACILITY NAME:CHAMPIONS @ CARROLL ELEMENTARYFACILITY NUMBER:
343612109
ADMINISTRATOR:DONYEALL ROBINSONFACILITY TYPE:
840
ADDRESS:10325 STATHOS DRIVETELEPHONE:
(916) 714-4362
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:50CENSUS: 6DATE:
03/14/2022
UNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Diana LopezTIME COMPLETED:
05:55 PM
ALLEGATION(S):
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Personal Rights-Teacher inappropriately handled child in care.
INVESTIGATION FINDINGS:
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On 03/14/2022 Licensing Program Analyst (LPA) Aruna Sridharan met with staff Diana Lopez to deliver the findings for the above allegation. During today's inspection LPA observed 6 children and another staff. It was alleged that a teacher inappropriately handled child in care. LPA conducted interviews with staff, children and parents which revealed that a staff member had flipped a child upside down. LPA also obtained pertaining documents. During the course of the investigation it was revealed that on at least one occasion, the staff member admitted that a child was flipped upside down and that it was in a fun way but interviews with children and parents revealed that they felt uncomfortable.

Based on the information gathered throughout the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, are being cited on the attached LIC9099-D.

The report continues on 9099C page..........
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Justin L DentonTELEPHONE: (916) -92-0269
LICENSING EVALUATOR NAME: Aruna SridharanTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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 3
Control Number 53-CC-20211210093437
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: CHAMPIONS @ CARROLL ELEMENTARY
FACILITY NUMBER: 343612109
VISIT DATE: 03/14/2022
NARRATIVE
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The following Type A deficiency was cited on the 9099-D page of this report.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. The LIC 9224 must be signed by parents/guardians and kept as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 is available on the website. Verification of receipt shall be kept in each child's file at the facility. An exit interview was conducted, and Appeal Rights were provided.
SUPERVISOR'S NAME: Justin L DentonTELEPHONE: (916) -92-0269
LICENSING EVALUATOR NAME: Aruna SridharanTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 53-CC-20211210093437
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: CHAMPIONS @ CARROLL ELEMENTARY
FACILITY NUMBER: 343612109
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2022
Section Cited
CCR
101223(a)(2)
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Personal Rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This evidence was not met as evidenced by;
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The director stated that she will not have any staff handle a child inappropriately.
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During the investigation, the staff had admitted to at least on one occassion flipped a child upside down.
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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: Justin L DentonTELEPHONE: (916) -92-0269
LICENSING EVALUATOR NAME: Aruna SridharanTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3