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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364844050
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:14:53 PM

Document Has Been Signed on 12/08/2021 02:14 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:KCE CHAMPIONS LLC@ PARK VIEW PREPARATORYFACILITY NUMBER:
364844050
ADMINISTRATOR:TATE JANE, TRACYFACILITY TYPE:
840
ADDRESS:13427 CAHUENGA ROADTELEPHONE:
(760) 713-0443
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 56TOTAL ENROLLED CHILDREN: 56CENSUS: 7DATE:
12/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Rebecca KinneyTIME COMPLETED:
02:29 PM
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Licensing Program Analysts (LPA's) Justin Dorsey and Babatunde Ibitoye spoke with director, Rebecca Kinney, for the purpose of conducting a follow-up on a Case Management Unusual Incident Report (UIR) from the facility. This UIR was received by Licensing on 12/03/2021.

Description of incident: On 12/01/21 Child #1 was swinging on the swings when Child #2 threw Child #1 a beanie. Child #1 let go of the swing in an attempt to catch the beanie and fell face forward into the sand. Child #1's nose began to bleed, staff did a head to toe check-asking questions, parent was notified and child was taken to get X-Rays.

During this investigation, LPA interviewed staff and Child #1. LPA's were was guided on a tour of the playground where the incident occurred. Based on interviews with staff and Child #1 LPA Dorsey found according to interviews the facility was in ratio on the playground at the time of the incident and observed the swing area to be free of hazards to children's health or safety.



Notice of Site Visit shall be posted for for thirty (30) consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

An exit interview was conducted with and a copy of this report has been signed by and provided to director Rebecca Kinney, Site Visit and Appeal Rights were given.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Justin Dorsey
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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