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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 334807508
Report Date: 07/09/2024
Date Signed: 07/09/2024 01:29:24 PM

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
07/01/2024 and conducted by Evaluator Susan Brewer
PUBLIC
COMPLAINT CONTROL NUMBER: 09-CC-20240701153148
FACILITY NAME:KCE CHAMPIONS LLC @ TOMAS RIVERA ELEMENTARYFACILITY NUMBER:
334807508
ADMINISTRATOR:DESIREE PADILLAFACILITY TYPE:
840
ADDRESS:20440 RED POPPY LANETELEPHONE:
(951) 653-9477
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY:66CENSUS: 24DATE:
07/09/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Director Daisy HernandezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of Supervision - Child sustained an injury while in care due to lack of care and supervision from staff
Reporting Requirements - Staff did not inform child's parent of serious injury sustained while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On the above date and time, Licensing Program (LPA) Analyst Susan Brewer arrived at the facility for the purpose of continuing a complaint investigation into the above allegations and to deliver findings. The LPA was greeted by Director Daisy Hernandez and Will Saxton, was granted entry to tour the facility inside and out. A census was taken of 24 children, supervised by 5 staff.

On 07/08/2024 the LPA Susan Brewer, initiated an investigation regarding allegations of Lack of Supervision and Reporting Requirements. The LPA made observations, reviewed records and conducted interviews with pertinent parties relevant to the investigation. On today’s date, the LPA met with the Directors Daisy Hernandez and Will Saxton, to continue the investigation.

1st allegation – It was alleged that on 06/26/2024 a child sustained an injury while in care due to lack of care and supervision from staff when a subject child injured their head on a pole in the outdoor activity area.
****Continued on LIC9099C Page 2****
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
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-20240701153148
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 @ TOMAS RIVERA ELEMENTARY
FACILITY NUMBER: 334807508
VISIT DATE: 07/09/2024
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
26
27
28
29
30
31
32
****LIC9099C Page 2****

1st Allegation- Lack of Supervision continued: The LPA conducted interviews with pertinent parties, reviewed facility records and made observations which revealed that on 06/26/2024, a child was injured while playing in the outdoor activity area, however the details of the time, location, equipment and the events leading up to the injury were unknown and there were no witnesses to the incident.

On 06/27/2024 a licensee representative notified the department of a Unusual Incident Report (UIR) that took place on 06/26/2024. In the report the licensee representative described in writing that a student reported bumping their head, the student cried and sought support from teachers on the playground for their injury. It was also reported that a staff assigned to supervise the child comforted the child after learning of the injury, however the staff did not observe when the injury occurred, nor did the staff offer medical treatment before allowing the child to return to play. Information gathered through pertinent parties interviewed indicated the injury took place when the child hit their head on the pole of a shade structure where benches are located, while other parties interviewed indicated the injury took place on the pole of a basketball backboard or that the details of the child’s injury were learned from another party. In addition, the information gathered lacked certainty of when and how the child injured their head, the type of equipment the child injured their head on, or when the injury happened. Based on the information gathered through record review, observations and pertinent interviews, and by the licensee’s own admission through a written notification to the department, the allegation is substantiated.

2nd allegation – It was alleged that facility staff did not inform a child's parent of a serious injury sustained while in care. LPA interviews with pertinent parties revealed that on 06/26/2024, a facility staff did not notify a subject child's authorized representative that the child was injured while in care, after hitting their head on a pole. On 06/27/2024 the day following the incident, a licensee representative notified the department of an Unusual Incident Report (UIR). In the written report, the licensee representative describes that a facility staff did not follow the licensee’s policies and procedures regarding incidents and/or accidents that occur involving a child and/or children, and failed to follow the necessary steps to report and document the events that took place.

****See LIC9099C Page 3****
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 09-CC-20240701153148
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 @ TOMAS RIVERA ELEMENTARY
FACILITY NUMBER: 334807508
VISIT DATE: 07/09/2024
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
26
27
28
29
30
31
32
****LIC9099C Page 3****

2nd Allegation - Reporting Requirements continued: Although the facility followed Title 22 requirements by self-reporting an incident that took place, it was written that the licensee representative learned details of the incident after being informed by the child’s authorized representative. In addition, by the licensee's own admission the facility staff failed to notify the child's authorized representative and failed to document details of the incident according to the agencies plan of operation and protocols. Based on the information gathered through record review, observations, interviews with pertinent parties, and by the licensee’s own admission through a written notification to the department, the allegation is substantiated.

Based on LPA’s observations and interviews which were conducted and reviews, the preponderance of evidence standard has been met, therefore the above allegations that a child sustained an injury while in care due to lack of care and supervision from staff and that a facility staff did not inform child's parent of serious injury sustained while in care, were found to be SUBSTANTIATED.

California Code of Regulations, Title 22, divisions & chapter number 101229(a)(1) Responsibility for Providing Care and Supervision and 101212(f) Reporting Requirements are being cited on the attached LIC 9099D pages.

LPA Susan Brewer informed the Directors, that this report documents a Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Susan Brewer informed the Directors, to provide a copy of this licensing report and that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report LIC9224, or other written statement, must be placed in the child's file for verification.

No civil penalties issued on today's date. Exit interview conducted and a copy of this report was provided to Directors Daisy Hernandez and Will Saxton, on this date. A Notice of Site (NOI) visit was issued and must remain posted for 30 days. The LPA observed the licensee post the NOI, prior to leaving the facility.
SUPERVISORS NAME: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 09-CC-20240701153148
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 @ TOMAS RIVERA ELEMENTARY
FACILITY NUMBER: 334807508
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2024
Section Cited
CCR
101229(a)(1)
1
2
3
4
5
6
7
101229(a)(1) The licensee shall provide care & supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time...and Supervision shall include visual observation. This regulation was not met as evidenced by:
1
2
3
4
5
6
7
The facility agrees to ensure the facility staff provide care & supervision to meet the needs of children by conducting training on playground procedures and will submit a plan training curriculum to address care & supervision on or before 07/10/2024.
8
9
10
11
12
13
14
Based on LPA interview, record review and the licensee's own admission, the facility failed to provide care & supervision necessary when a child obtained an injury while in care unknown to the facility staff which is an immediate health & safety risk to to children in care.
8
9
10
11
12
13
14
In addition the facility agrees to submit proof of staff participation and completion of training to the department on or before 7/19/2024, through fax, mail or e-mail.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 09-CC-20240701153148
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 @ TOMAS RIVERA ELEMENTARY
FACILITY NUMBER: 334807508
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2024
Section Cited
CCR
101212(f)
1
2
3
4
5
6
7
101212(f) Reporting Requirements
(f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.
This regulation was not met as evidenced by:
1
2
3
4
5
6
7
The facility agrees to ensure the facility staff provide are aware of reporting requirements by conducting training on incident reporting procedures and will submit a plan along with the training curriculum to address reporting requirements on or before 07/10/2024.
8
9
10
11
12
13
14
Based on LPA interview, record review and by the licensee's own admission, the facility failed to report an incident where a child was injured to a child's authorized representative which is a potential risk to the health and safety of children in care.
8
9
10
11
12
13
14
In addition the facility agrees to submit proof of staff participation and completion of the training to the department on or before 7/19/2024, through fax, mail or e-mail.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Ana Noble
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5