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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334807508
Report Date: 11/10/2021
Date Signed: 11/10/2021 03:30:15 PM

Document Has Been Signed on 11/10/2021 03:30 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 @ TOMAS RIVERA ELEMENTARYFACILITY NUMBER:
334807508
ADMINISTRATOR:MARI WALSHFACILITY TYPE:
840
ADDRESS:20440 RED POPPY LANETELEPHONE:
(951) 653-9477
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY: 66TOTAL ENROLLED CHILDREN: 66CENSUS: 27DATE:
11/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Smia Samain, DirectorTIME COMPLETED:
03:25 PM
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On the date and time listed above, a case management visit was conducted by Licensing Program Analyst (LPA) Giselle Carbullido to deliver an amended report. During today’s visit, LPA toured the facility and census was taken, with 27 children present. LPA met with Samia Samain, Director to deliver an amended report.

Exit interview conducted and a copy of this report and notice of site visit was provided to the Director. A copy of this report must be made available to the public for 3 years.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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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