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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 334805794
Report Date: 08/09/2024
Date Signed: 08/09/2024 09:41:37 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2024 and conducted by Evaluator Giselle Carbullido
PUBLIC
COMPLAINT CONTROL NUMBER: 09-CC-20240718103053
FACILITY NAME:KCE CHAMPIONS LLC @ CASTLE VIEW ELEMENTARY SCHOOLFACILITY NUMBER:
334805794
ADMINISTRATOR:JESSICA MCGINNISFACILITY TYPE:
840
ADDRESS:6201 SHAKER DRIVETELEPHONE:
(951) 786-9025
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:60CENSUS: 0DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Aranna DyeTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff did not notify responsible party of incident.
INVESTIGATION FINDINGS:
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On the date and time listed above, Licensing Program Analyst (LPA) Giselle Carbullido arrived at the facility to investigate regarding the above complaint received on 07/18/24. An initial and subsequent visit were conducted on 07/22/24 and 08/06/24 respectively at which time LPA conducted interviews and reviewed records. Additional, collateral interviews were conducted on 07/31/24 and 08/09/24. LPA was given access to the facility by the Director, Aryanna Dye. LPA discussed purpose of visit, took census, and toured the facility. LPA met with the Director to further discuss the complaint allegations and deliver findings
It was alleged staff did not notify the parent when their child became ill and almost passed out during an off-site field trip. LPA interviewed all pertinent parties, including facility staff and children.
During the date of the alleged incident, pertinent parties stated most of the activities were outdoors, and acknowledged it was a ‘very’ hot day requiring staff and children to drink extra water. Pertinent parties stated a child reported stomach pains, feeling hot and dizzy, while keeping their head down on the table.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 09-CC-20240718103053
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KCE CHAMPIONS LLC @ CASTLE VIEW ELEMENTARY SCHOOL
FACILITY NUMBER: 334805794
VISIT DATE: 08/09/2024
NARRATIVE
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Pertinent parties stated first aid and monitoring was provided by having child rest indoors and eat/drink prior to resuming activities. Staff stated they failed to notify the child’s authorized representative of the incident and first aid measures needed for the physical health and safety of the child.
Based on the information gathered from interviews conducted and facility staff’s own admission, the allegation is SUBSTANTIATED. See LIC809D for deficiency cited.
Appeal rights issued and discussed with licensee and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of this report and Notice of Site Visit was provided to Aryanna Dye. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC FOR THREE YEARS.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 09-CC-20240718103053
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KCE CHAMPIONS LLC @ CASTLE VIEW ELEMENTARY SCHOOL
FACILITY NUMBER: 334805794
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2024
Section Cited
CCR
101212(f)
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Reporting Requirements- 101212(f):
(f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.
This requirement is not met as evidenced by:
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Facility will submit Unusual incident report and a written letter of understanding for reporting requirements: (f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative by POC due date 08/12/24.
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Based on interviews conducted the facility failed to notify a parent regarding an incident about the physical health and safety of their child. This is a potential risk to the health and safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5