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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841007
Report Date: 11/19/2024
Date Signed: 11/19/2024 08:19:15 AM

Document Has Been Signed on 11/19/2024 08:19 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 @ WOODCREST ELEMENTARY SCHOOLFACILITY NUMBER:
334841007
ADMINISTRATOR/
DIRECTOR:		CAMMIE DONAGHYFACILITY TYPE:
840
ADDRESS:16940 KRAMERIA AVENUETELEPHONE:
(951) 780-1215
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 35TOTAL ENROLLED CHILDREN: 35CENSUS: 19DATE:
11/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:40 AM
MET WITH:Cammie DonaghyTIME VISIT/
INSPECTION COMPLETED:
08:25 AM
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 11/12/24 and indicates facility was out of ratio on 11/08/24 from 8AM to 8:30AM . The LPAs were greeted and granted entry by Site Director, Cammie Donaghy. A census was conducted of 19 children present and supervised by 2 staff.
Facility records were reviewed, and interview conducted with Site Director. Based on the information gathered, the following violations have been identified: CCR 101516.5(b)(1) Teacher-Child Ratio
(b) There shall be a staffing ratio of 1 teacher & 1 aide present to every 28 children. (1) A teacher shall supervise no more than 14 children or with an aide a maximum of 28 children.
See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12.
An exit interview was conducted, appeal rights discussed, notice of site visit and a copy of this report was provided to Site Director, Cammie Donaghy
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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Document Has Been Signed on 11/19/2024 08:19 AM - It Cannot Be Edited


Created By: Giselle Carbullido On 11/19/2024 at 08:02 AM
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 @ WOODCREST ELEMENTARY SCHOOL
FACILITY NUMBER: 334841007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
101516.5(b)(1)

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101516.5(b)(1): Teacher-Child Ratio- (1) A teacher shall supervise no more than 14 children or with an aide a maximum of 28 children. This regulation was not met as evidenced by:
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The facility agrees to create a plan to ensure staffing ratio in that a teacher shall supervise no more than 14 children by POC due date of 11/22/2024.
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Based on the agency's self - reported Unusual Incident, on 11/08/2024 a facility staff was left to supervise 18 children alone, for approximately 30 minutes from , 8:00 AM - 8:30 AM, which is a potential risk to the health & safety of children 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: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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