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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701382
Report Date: 11/05/2019
Date Signed: 11/05/2019 05:55:44 PM

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 @ KAVODFACILITY NUMBER:
376701382
ADMINISTRATOR:MARISSA LUJANFACILITY TYPE:
840
ADDRESS:6991 BALBOA AVENUETELEPHONE:
(858) 221-3744
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:56CENSUS: 35DATE:
11/05/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:16 PM
MET WITH:Marissa LujanTIME COMPLETED:
06:00 PM
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Licensing Program Analysts (LPAs) Selina Siao and Elizabeth Rivera conducted a case management visit to follow-up a self reported incident on 10/16/2019. The incident involved a child that fell off the swing onto the rubber cushioning. The The swing's seat corner hit the side of the child's head causing a small laceration. The incident was reported to licensing within the 24 hours requirement. The incident was observed by a staff during the incident. There were no apparent hazards accessible to children. The incident appears accidental, the facility took prompt action by administering first aid and notifying the parent.

LPA inspected the swing set and it is age appropriate for children 5-12 years old and there is soft rubber cushioning under and around the swing set. Staff also proceeded to review playground safety rules with children in care.

Exit interview conducted with the facility assistant director. The program at the facility appears to be within substantial compliance today and no violations are noted from the incidents per CCR, Title 22 regulations governing child care centers. No deficiencies cited.

A Notice of Site Visit was posted today, and Site Director was explained that it must remain posted for a period or 30 days. Failure to keep notice posted will result in a civil penalty of $100.00

SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Selina SiaoTELEPHONE: (619) 767-2217
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2019
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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