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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334807508
Report Date: 12/07/2023
Date Signed: 12/07/2023 06:25:13 PM

Document Has Been Signed on 12/07/2023 06:25 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
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: 66TOTAL ENROLLED CHILDREN: 24CENSUS: 17DATE:
12/07/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Karla Mora and TIME COMPLETED:
06:35 PM
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On 12/07/2023 at 2:07 PM Licensing Program Analyst (LPA) Susan Brewer, arrived at the facility to conduct a 1 year required annual inspection. LPA was granted entry by Substitute Teacher Karla Mora. LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following: The site director Daisy Hernandez, was not present at the facility. Site director Desiree Padillia is no longer working at the facility. At 4:10 PM Diana Navarrette, Facility Coach arrived to join the inspection, finish the tour of the facility and sign the report.

Normal days and hours of operation: Morning Session M/T/TH/F, 6:00 AM to 8:10 AM and Afternoon Session is 2:30 PM to 6:30 PM and Wed afternoons 1:15 PM to 6:00 PM in the portable module North of the school.

The inspection consisted of reviews of the following domains: Food Service; Reporting Requirements
Physical Plant; Care and Supervision; Children Records; Staff Records; Staffing Ratio and Capacity and
Personal Rights. The inspection found the facility to be in compliance in these domains.

The licensee is asked to update the following documents, if applicable, and submit to licensing within 30 days if changes have been made on or before 01/07/2024

1. LIC 500 Personnel Report, need update.
2. LIC 610 Emergency & Disaster Plan, need update.
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made), need update.
4. LIC 999 Facility Sketches for changes to the designated indoor & outdoor activity areas (Multi-Purpose RM no longer primary area) and changes to the designated restrooms, staff restroom and isolation areas..
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KCE CHAMPIONS LLC @ TOMAS RIVERA ELEMENTARY
FACILITY NUMBER: 334807508
VISIT DATE: 12/07/2023
NARRATIVE
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Continued: update the following documents to submit to licensing within 30 days if changes have been made on or before 01/07/2024
5. LIC 309 Administrative Organization, Need update
6. LIC 308 Designation of Administrative Responsibility, Need update
7. LIC 200A Application for changes for New Director
8. Waiver request for daycare children to share restrooms with elementary school children.
9. Waiver request for daycare children to share the outdoor activity area with elementary school children.

The following items have been posted and are updated where necessary:
- License, Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
- Parent’s Rights Poster (PUB393), Personal Rights (LIC613A); Child Car Seat Law, Menu.
· The facility is operating within the terms of the license.
· Facility is clean, safe and sanitary and in good repair.
· Ratios were met during this inspection. LPA took a census of 17 children supervised by 2 staff.
· A fully charged fire extinguisher (2A:10BC) in the green and tagged for 06/08/2023. K. Mora tested a carbon monoxide detector to be working. The 2 smoke detectors tested during today’s inspection were observed to be inoperable and/or expired.
· Appropriate supervision was provided during this inspection.
· Classrooms are equipped with age-appropriate furniture and equipment in good condition.
· Classrooms are clean and free of hazards.
· All materials and surface accessible to children are toxic free.
· No weapons stored at the facility.
· There are no bodies of water present on 12/07/2023. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· There are no Medications currently stored at the facility and no IMS services being provided to children.
· Center is equipped to isolate and care for any child who becomes ill during the day.
· Hazards are stored where inaccessible to children which include: disinfectants, cleaning solutions and other items that are dangerous to children
· All floors shall be clean and safe.
· Measures are taken to keep the facility free of flies, other insects and rodents.
· Toxins are key locked in a storage room.
· Bathrooms were observed to be safe, sanitary and in operating condition.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KCE CHAMPIONS LLC @ TOMAS RIVERA ELEMENTARY
FACILITY NUMBER: 334807508
VISIT DATE: 12/07/2023
NARRATIVE
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· Playgrounds are enclosed by appropriate fences and free of hazards.
· Outdoor activity areas are supplied with age and size appropriate equipment in good condition.
· Food preparation area is clean and free of vermin.
· Food is stored appropriately and protected from contamination.
· All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair.
· Uncontaminated drinking water shall be readily available both indoors and out and is provided by tap water, bottled water, disposable cups and individual cups.
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall by natural grass. .
· Menus shall be posted at least one week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days, and made available upon request.
· Sign in/Sign out record was reviewed and meets regulation requirements on 12/07/2023.
· A Staff member is present with current Pediatric CPR/First Aid which expires on 01/2024.
· Opening and closing staff member’s CPR/First Aid expires on 01/2024.
· Director completed Health and Safety Training: NOT ON FILE
· Staff qualifications and files were reviewed and are NOT complete on 12/07/2023. A subject staff present, were missing proof of Health, Safety, Nutrition and Lead Certificate, LIC308 Designation of Authority, LIC503 Health Screening to ensure health requirements for performing assigned tasks, and although it was determined that staff present and caring for children were fingerprint cleared to work with daycare children, LPA was only able to verify that 1 of 2 staff present and working was associated to the facility by the licensee.
· Staff received on the job training for housekeeping, sanitation and universal health precautions.
· Each child’s file is complete on 12/07/2023.
· Licensee was informed of the Department has inspection authority per Health and Safety Codes.
· Documentation of Lead Testing is on file: Sample testing completed on 12/14/2022 and results reported on 01/04/2023 indicate no action level exceedance detected.
· A review of staff records on 12/07/2023 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KCE CHAMPIONS LLC @ TOMAS RIVERA ELEMENTARY
FACILITY NUMBER: 334807508
VISIT DATE: 12/07/2023
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The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov. During the inspection, the licensee submitted proof of association for 1 of 2 subject staff members present to supervise daycare children.

This facility does not currently provide Incidental Medical Services – IMS. LPA Susan Brewer, did not observe storage of medication and equipment/supplies, and no children’s medical records currently to review. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm For FCCHs: Incidental Medical Services (IMS) policy was discussed.

Diana Navarrette, was reminded that all adults 18 and over working in the facility, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. The

Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov for Riverside Regional Office.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Deficiencies cited for Type B violations this visit.
Civil Penalties were not issued this visit.
A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with Diana Navarrette.
SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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Document Has Been Signed on 12/07/2023 06:25 PM - It Cannot Be Edited


Created By: Susan Brewer On 12/07/2023 at 05:31 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
FACILITY NUMBER: 334807508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in the facility has 2 inoperable smoke detectors in the indoor activity area, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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The licensee agrees to submit proof of newly installed smoke detectors to the department on or before 12/15/2023.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in a supervising staff present and working with daycare children was unable to provide proof of immunizations against influenza, pertussis, and measles as required, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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The licensee agrees to ensure a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. The licensee also agrees to submit proof of immunization records to show vaccinations against influenza, pertussis, and measles for a subject staff, on or before 12/29/2023.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2023 06:25 PM - It Cannot Be Edited


Created By: Susan Brewer On 12/07/2023 at 05:31 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
FACILITY NUMBER: 334807508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101215.1(m)
Child Care Center Director Qualifications and Duties
(m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview record review, the licensee did not comply with the section cited above in the licensee failed to ensure that at least 1 supervising staff presently substituting in place of the director and caring for children at the facility had proof 16 hours of health and safety training, necessary pursuant to Health and Safety Code Section 1596.866., which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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The licensee agrees to ensure that a child care center director or substitute for the director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866 and submit proof of participation and completion of the required training to the department on or before 01/12/2023.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview record review, the licensee did not comply with the section cited above in the licensee failed to ensure that a subject staff member present and working with daycare children had proof of a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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The licensee agrees to ensure that all employees are tested for tuberculosis, and the testing is performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. the licensee also agrees to submit proof of a TB screening to the department for a subject staff on or before 12/29/2023.
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:Kimberly Williams
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 12/07/2023 06:25 PM - It Cannot Be Edited


Created By: Susan Brewer On 12/07/2023 at 05:31 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
FACILITY NUMBER: 334807508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in the facility did not ensure that a supervising staff present and caring for daycare children had a health-screening report LIC503 signed by the person performing the screening, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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The licensee agrees to ensure that each person employed to work with daycare children shall have a health-screening report signed by the person performing the screening, a licensed medical physician and submit proof of the report to the department on or before 12/29/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberly Williams
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


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