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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610172
Report Date: 05/31/2022
Date Signed: 05/31/2022 02:15:34 PM

Document Has Been Signed on 05/31/2022 02:15 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HOME OF CHAMPIONS LLCFACILITY NUMBER:
197610172
ADMINISTRATOR:CHAMBERS, TAMMY SHURELLFACILITY TYPE:
735
ADDRESS:27457 CAMP PLENTY RD.TELEPHONE:
(661) 309-4666
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91351
CAPACITY: 4CENSUS: DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:TIME COMPLETED:
02:12 PM
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Licensing Program Analyst (LPA) Abeye Duguma attempted to conduct an unannounced one year infectious control annual visit but to no avail. LPA knocked on the door and rang the door bell several times and no one answered. LPA did not hear or see any activity at the home. LPA attempted to contact the facility administrator, Tammy Chambers, and there was no answer. LPA left a detailed voice message. The Administrator later called and stated that the facility has one resident who is at work and that she will be picking up the resident later today. LPA asked if there was anyone else that might be able to open the facility and the Administrator replied, "no".

Attempted visit completed. No further action at this time.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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