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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334807508
Report Date: 02/27/2025
Date Signed: 02/27/2025 06:23:54 PM

Document Has Been Signed on 02/27/2025 06:23 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KCE CHAMPIONS LLC @ TOMAS RIVERA ELEMENTARY SCHOOLFACILITY NUMBER:
334807508
ADMINISTRATOR/
DIRECTOR:		DESIREE PADILLAFACILITY TYPE:
840
ADDRESS:20440 RED POPPY LANETELEPHONE:
(951) 653-9477
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY: 66TOTAL ENROLLED CHILDREN: 46CENSUS: 16DATE:
02/27/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Tori GaymanTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On 02/27/2025 at 1:15 PM, Licensing Program Analyst (LPA) Tiffanie Diep met with Director Tori Gayman for the purpose of an unannounced case management inspection to follow up on an Unusual Incident Report (UIR) received by the Department on 02/18/2025. The incident was reported by the facility within the required timeframe. Director guided LPA on a tour of the facility. LPA did not observe any day care children at the facility at the beginning of the inspection. All individuals subject to a criminal record review have obtained a criminal record clearance.

LPA made observations at the facility, obtained supporting documentation pertinent to the incident, and conducted interviews with pertinent individuals involved in the incident during today's visit. Interviews conducted disclosed a staff member called out late for the morning session scheduled for 6:00 AM to 8:00 AM. It was disclosed the facility attempted to secure a substitute staff member prior to the scheduled shift. Information obtained revealed the facility was unable to secure a substitute staff member until the morning session ended. Records reviewed indicated the staff member supervised 19 children alone for approximately 30 minutes between 7:25 and 7:55 AM.

Based on observations made at the facility, information obtained during interviews, and records reviewed, a deficiency is being cited on the attached LIC 809-D. LPA Tiffanie Diep informed the director, Tori Gayman, that this report dated 02/27/2025 documents one Type B citation as there was a potential risk to the safety of children in care.

An exit interview was conducted and report was reviewed with the director, Tori Gayman. A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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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Document Has Been Signed on 02/27/2025 06:23 PM - It Cannot Be Edited


Created By: Tiffanie Diep On 02/27/2025 at 04:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KCE CHAMPIONS LLC @ TOMAS RIVERA ELEMENTARY SCHOOL
FACILITY NUMBER: 334807508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2025
Section Cited
CCR
101516.5(b)(1)

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101516.5 Teacher-Child Ratio (b) There shall be a staffing ratio of one teacher and one aide present to every 28 children in attendance. (1) A teacher shall supervise no more than 14 children...

This requirement is not met as evidenced by:
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LPA discussed staffing ratio requirement with Director. Director agreed to provide LPA with a written plan of action describing how they will prevent a similar incident from occurring in the future by 03/27/2025.
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Based on interviews conducted and records reviewed, it was revealed that a staff member supervised 19 children alone for 30 minutes which poses a potential safety risk to 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.
SUPERVISOR'S NAME:Ana Noble
LICENSING EVALUATOR NAME:Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
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