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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701389
Report Date: 10/16/2019
Date Signed: 10/16/2019 11:01:00 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
FACILITY NAME:KCE CHAMPIONS LLC @ SERRA MESAFACILITY NUMBER:
376701389
ADMINISTRATOR:DANIELLE CAVANAUGHFACILITY TYPE:
840
ADDRESS:2285 MURRAY RIDGE ROADTELEPHONE:
(858) 264-9561
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY:56CENSUS: 0DATE:
10/16/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ryan Elliott, Executive Director TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) D. Sanchez, made an unannounced follow up Case Management inspection to the facility today in response to an Unusual Incident/Injury Report received in the San Diego Child Care Regional Office (SDCCRO) on 9/23/2019. Incident report states that on 9/20/2019, child #1 was swinging on a handlebar on the playground. Child #1 asked child #2 to pushed her so she can go higher. Child #1 fell off the bar onto her arm sustaining injury on elbow.

LPA inspected the playground where the incident occurred, interviewed staff and children involved.

LPA and Licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.
Community Care Licensing WEB SITE: http://www.ccld.ca.gov

An exit interview was conducted with Ryan Elliott and a copy of this report left at the facility.
LPA observed provider placing the Notice of Cite Visit on the wall visible to parents during today’s inspection.

NOTICE OF SITE VISIT MUST BE POSTED FOR 30 DAYS
SUPERVISOR'S NAME: Jason GarayTELEPHONE: (619) 767-2250
LICENSING EVALUATOR NAME: Diana SanchezTELEPHONE: (619) 767- 2210
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
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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