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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334819673
Report Date: 07/22/2024
Date Signed: 07/22/2024 09:04:32 AM

Document Has Been Signed on 07/22/2024 09:04 AM - 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: 26DATE:
07/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:55 AM
MET WITH:Kimberly BanksTIME VISIT/
INSPECTION COMPLETED:
09:10 AM
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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. It indicates an inappropriate interaction between children.
Facility records were reviewed, and pertinent party interviews were conducted, including 6 staff and 4 children. Based on information gathered, the facility acted appropriately, and no violations have been identified. Facility reported timely; provided supervision; and notified authorized representatives. Facility completed reporting requirements and submitted an Unusual Incident Report (UIR) as required per CCR Title 22 Division 12 regulations.
An exit interview was conducted, and a copy of this report, appeal rights and notice of site visit were provided to facility representative, Kimberly Banks.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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