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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330911402
Report Date: 10/04/2022
Date Signed: 10/04/2022 03:20:30 PM

Document Has Been Signed on 10/04/2022 03:20 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KCE CHAMPIONS LLC @ MAGNOLIA ELEMENTARY SCHOOLFACILITY NUMBER:
330911402
ADMINISTRATOR:DEBORAH HILLFACILITY TYPE:
840
ADDRESS:3975 MAPLEWOOD PLACETELEPHONE:
(951) 313-2398
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 75TOTAL ENROLLED CHILDREN: 75CENSUS: 15DATE:
10/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Gabriella VallescoTIME COMPLETED:
03:30 PM
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On the date and time listed above, a case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 09/21/2022. It indicates a child sustained an injury while climbing on furniture.

Facility records were reviewed, and interviews were conducted with Director, Child and Parent.



According to staff interviews conducted, There were 6 children present with 1 staff (Director) on AM shift. Director interview reported child is new (attended one week) and unexpectedly ran and jumped onto the desk, fell backwards while holding desk resulting in an injury to teeth and mouth. Director interview reported Parents and EMS- paramedics were called. Parent followed up with medical and dental services. Director reported child returned to the facility.

Child interview reported they climbed onto table, fell off and hurt their teeth.

Parent interview stated facility notified them in a timely fashion, provided care and EMS services and provided an incident report. Parent stated their child informed them they climbed onto the table and fell off resulting in injury. Parent reported child is fine, has a tendency to climb at home and has returned to school and daycare.

At 2:30 PM, LPA toured and obtained photos of the school age indoor activity area. LPA did not observe any hazards present in the classroom or on any of the flooring. The table was a staff desk and was secure.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KCE CHAMPIONS LLC @ MAGNOLIA ELEMENTARY SCHOOL
FACILITY NUMBER: 330911402
VISIT DATE: 10/04/2022
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Based on information gathered from interviews and records, the facility acted appropriately, and no violations have been identified. Facility completed reporting requirements as required by CCR regulations for Unusual Incident Reports (Telephone notification to Duty Officer and submission of LIC624) to the California Department of Social Services. Facility contacted parent and EMS paramedics for additional medical follow up and maintained staff to children ratio(1:14) for supervison.

An exit interview was conducted, and LPA Carbullido provided the Director with a copy of this report, appeal rights and notice of site visit during today’s visit.



SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC809 (FAS) - (06/04)
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