<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623670
Report Date: 02/27/2023
Date Signed: 02/27/2023 11:39:19 AM

Document Has Been Signed on 02/27/2023 11:39 AM - 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:KCE CHAMPIONS LLC @ STONE RIDGEFACILITY NUMBER:
313623670
ADMINISTRATOR:HOLLOWAY, AMARAFACILITY TYPE:
840
ADDRESS:2501 ALEXANDRA DRTELEPHONE:
(916) 757-3244
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 2DATE:
02/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Amara HollowayTIME COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 02/27/2023 Licensing Program Analyst (LPA) Jeremey McClain met with Licensing Representative Amara Holloway for an unannounced Case Management Inspection.

LPA observed care and supervision of two school aged children by two staff.

LPA obtained documents necessary for the investigation of the incident reported on 02/22/23.

This report was reviewed with the licensing representative and a Notice of Site Visit was provided, which must remain posted for 30 days.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1