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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343612109
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:20:22 PM


Document Has Been Signed on 04/21/2022 04:20 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



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: 22DATE:
04/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Diana Lopez TIME COMPLETED:
04:30 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
Licensing Program Analyst (LPA) Stacey Williams met with Facility Representative to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 04/20/2022. During today's inspection the facility was toured. There were (22) twenty two school age children supervised by four staff.

LPA interviewed three staff during the inspection. Staff that were interviewed confirmed they were present in the facility when the incident occurred. Interviews conducted revealed that a child (C1) was left unattended outside on the fenced blacktop/grass play area after the childcare children were escorted back into the facility. C1 was out of staff's line of sight for approximately five minutes before a parent brought to their attention C1 was left outside. The incident report submitted listed the duration (C1) was left outside as two minutes. Based on the information obtained LPA determined C1 was left unattended.

The facility reported the unusual incident report (UIR) to Community Care Licensing detailing the specifics of the incident.

Facility evaluation report was reviewed and discussed with the Facility Representative. Title 22 Deficiency is being cited on the subsequent LIC 809-D page. Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 809-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809-D in each child's file.

LPA reviewed the report with Facility Representative. Site Supervisor was contacted via telephone during the exit interview to discuss the plan of correction. Appeal Rights were provided and Notice of Site Visit was posted. Notice of Site Visit must remain posted for 30 days.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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 2


Document Has Been Signed on 04/21/2022 04:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2022
Section Cited

1
2
3
4
5
6
7
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.

(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Community Care Licensing was notified by staff that C1 was left unattended outside on the fenced blacktop/grass play area after the childcare children were escorted into the facility. This poses an immediate risk to the health and safety of children in care.
8
9
10
11
12
13
14
Civil pentalties assessed.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2