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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842893
Report Date: 09/13/2022
Date Signed: 09/13/2022 03:09:46 PM

Document Has Been Signed on 09/13/2022 03:09 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 @ TAFT ELEMENTARY SCHOOLFACILITY NUMBER:
334842893
ADMINISTRATOR:RONYA GOUMMAFACILITY TYPE:
840
ADDRESS:959 MISSION GROVE PARKWAY N.TELEPHONE:
(951) 312-4094
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 19DATE:
09/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ronya Goumaa, Site DirectorTIME COMPLETED:
03:15 PM
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On 09/13/2021 at 2:00PM 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 09/07/2022. It indicates that one child touched another child in the private area.

Facility records were reviewed and staff interviews were conducted with Site Director and Teachers. Based on information gathered, the facility acted appropriately, and no violations have been identified.

At this time, the facility took appropriate action by completing self-reporting requirements as required for Unusual Incidents: Notifying the Duty Officer and submitting the LIC624 (UIR) to the Department of Social Services; providing direct observation and proper ratio for supervision; communicating with Parent/Guardian; and following program progressive discipline as outlined in the Parent/Family Handbook per program policy. Facility also reported incident to CPS- child protective services.

There are no deficiencies cited. An exit interview was conducted, Notice of Site Visit issued, and a copy of this report was provided to the Licensee.

A copy of this report must be made available to the public upon request for 3 years.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
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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