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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701101
Report Date: 11/16/2022
Date Signed: 11/16/2022 05:00:04 PM


Document Has Been Signed on 11/16/2022 05:00 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:SARAH REHARTFACILITY TYPE:
840
ADDRESS:6230 DEL CERRO BOULEVARDTELEPHONE:
(916) 387-5761
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:224CENSUS: 32DATE:
11/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Sarah RehartTIME COMPLETED:
04:59 PM
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On 11/16/22, LPA, Tyra Block conducted a Case Management Visit to discuss the recent self-reported incident. LPA spoke with Site Supervisor, Sarah Rehart to obtain additional facts regarding the incident. The facility has also made their administration aware of the situation and they have provided resources to assist staff and support the family. LPA obtained parent information for possible follow up. No further action necessary at this time. No deficiencies cited.
SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 767-2242
LICENSING EVALUATOR NAME: Tyra BlockTELEPHONE: (619) 767-2201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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