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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701382
Report Date: 09/14/2022
Date Signed: 09/27/2022 04:29:01 PM


Document Has Been Signed on 09/27/2022 04:29 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/22/2022 09:01 AM

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

NARRATIVE
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Licensing Program Analyst (LPA) Jennifer Lott conducted an unannounced Case Management visit. LPA was greeted at the front of the facility by Director, Alexia Morales and was granted entry after identifying herself and disclosing the purpose of her visit.

The visit was initiated due to a self-reported incident involving child #1 (C1) eloping out of sight from staff. The child was located approximately 25 minutes later. The licensee’s authorized representative self-reported this incident by submitting form LIC 624 – Unusual Incident/Injury Report to Community Care Licensing (CCL), which was received in our office on 04/18/2022.

During today’s visit, LPA interviewed staff.

Based on today’s visit, deficiencies were observed and noted on the attached LIC 809D. Exit interview conducted and report was reviewed with Director, Morales. A notice of site visit was given and must remain posted for 30 days.

LPA Lott informed Director, Morales that this report dated 09/14/2022 documents one (1) type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health & safety of children in care.

Also, LPA Lott informed Director, Morales to provide a copy of this licensing report dated 09/14/2022 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

This is an amended version of the original report created on 09/14/2022.

SUPERVISOR'S NAME: Tashima DanielTELEPHONE: (619) 629-8413
LICENSING EVALUATOR NAME: Jennifer LottTELEPHONE: 619-782-8300
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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Document Has Been Signed on 09/27/2022 04:29 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/22/2022 09:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 KAVOD
FACILITY NUMBER: 376701382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2022
Section Cited

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Responsibility for Providing Care & Supervision - ..."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."
This requirement is not met as evidenced by:
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Based on documentation & interviews, C1 eloped out of sight from staff, being located approximately 25 minutes later. This poses an immediate health & safety risk to children in care.
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This is an amended version of the original report created on 09/14/2022.

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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: Tashima DanielTELEPHONE: (619) 629-8413
LICENSING EVALUATOR NAME: Jennifer LottTELEPHONE: 619-782-8300
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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