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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701389
Report Date: 05/05/2022
Date Signed: 05/05/2022 05:05:15 PM


Document Has Been Signed on 05/05/2022 05:05 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 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: 28DATE:
05/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Isabella Alvarez DeLa CampaTIME COMPLETED:
05:15 PM
NARRATIVE
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On 5/5/22 at 2:55 PM, Licensing Program Analyst (LPA) Keturah Lane conducted an unannounced case management inspection to follow up on an unusual incident reported by the facility about a week ago. LPA Lane met with Baleigh Salla who stated she was filling in briefly for Site Director Isabella Alvarez DeLa Campa. Also present was teacher Jocelyn De La Riva. Census was 28 children. LPA Lane set up equipment in multi-purpose room and then Site Director entered a few minutes later. Site Director toured playground with LPA to show where the incident happened. LPA Lane interviewed Site Director and staff member Jocelyn De La Riva as well as the three children involved in the reported incident. Based upon interviews, it was determined that the incident happened within 2 minutes and staff member was on her way to investigate. The facility took immediate action by reporting the incident to Licensing, closed the area of the playground to the children and spoke to the children regarding the incident and appropriate behavior.

No deficiencies were cited.
Exit interview conducted and report was reviewed with Site Director, Isabella Alvarez DeLaCampa. Notice of site visit was provided and must be posted for 30 days.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Keturah LaneTELEPHONE: (619) 767-2223
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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