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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334819673
Report Date: 07/11/2024
Date Signed: 07/12/2024 12:18:15 PM

Document Has Been Signed on 07/12/2024 12:18 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 @ MARK TWAIN ELEMENTARY SCHOOLFACILITY NUMBER:
334819673
ADMINISTRATOR/
DIRECTOR:		DEBORAH HILLFACILITY TYPE:
840
ADDRESS:19411 KRAMERIA AVETELEPHONE:
(951) 640-5943
CITY:RIVERSIDESTATE: CAZIP CODE:
92508
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 14DATE:
07/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Kimberly Banks/ Cammie Donaghy, Site DirectorsTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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A case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 07/02/24.

Facility records were reviewed, and pertinent party interviews were conducted, including six staff and four children. Regarding the UIR submitted, further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee/facility representative.

During the course of this visit, LPA requested children records for review and was informed for three records not available for review or completed as required.
See LIC809D for deficiency cited per the CCR Title 22 regulation:
101221(a) Child's Records: (a) A separate, complete and current record for each child is maintained in the child care center.

An exit interview was conducted, and a copy of this report, appeal rights and notice of site visit were provided to facility representatives.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/12/2024 12:18 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 07/12/2024 at 12:02 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 @ MARK TWAIN ELEMENTARY SCHOOL
FACILITY NUMBER: 334819673

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2024
Section Cited
CCR
101221(a)

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Child's Records:101221(a) A separate, complete and current record for each child is maintained in the child care center.
This requirement is not met as evidenced by:
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Facility will submit to the department a complete record for the three children by POC due date of 07/15/24.
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Based on interview and record review, the licensee did not comply with the section cited above in that three children records were not available for review or completed per Site Directors which poses a potential health, safety or personal rights risk to persons 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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
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