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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701101
Report Date: 03/16/2022
Date Signed: 03/16/2022 04:12:18 PM


Document Has Been Signed on 03/16/2022 04:12 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108



FACILITY NAME:KCE CHAMPIONS LLC AT HEARST ELEMENTARYFACILITY NUMBER:
376701101
ADMINISTRATOR:ALMA MEJIAFACILITY TYPE:
840
ADDRESS:6230 DEL CERRO BOULEVARDTELEPHONE:
(916) 387-5761
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:224CENSUS: 60DATE:
03/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:17 PM
MET WITH:Alma MejiaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA), Tyra Block conducted a Case Management visit to follow up on a self-reported incident that occurred at the facility on 2/24/22 involving a child mishandling a stapler and stapling another child's elbow. LPA was greeted by Site Director, Alma Mejia. Present today were 60 children (Purple-10, Green-15, Blue-15, Yellow-8, and Red 12) with 9 staff. All staff were cleared and associated to the facility.

Ms. Alma informed LPA that the children involved had already left for the day, as it was minimum day. LPA obtained the children's facility roster and interviewed staff, Zen Flores, who witnessed the incident.

No deficiencies were cited during this visit.

A Notice of Site Visit was provided and must be posted for 30 days.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Tyra BlockTELEPHONE: (619) 767-2201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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