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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610172
Report Date: 06/22/2022
Date Signed: 06/22/2022 02:37:08 PM

Document Has Been Signed on 06/22/2022 02:37 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:
06/22/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:TIME COMPLETED:
02:13 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. There were no cars in the driveway. LPA attempted to contact the facility administrator, there was no answer and voicemail was full. This is the second attempt.

No further action at this time.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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