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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376105060
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:27:43 PM

Document Has Been Signed on 03/10/2022 03:27 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KCE CHAMPIONS LLC AT ELEVATE MIDDLEFACILITY NUMBER:
376105060
ADMINISTRATOR:JOCELYN HERNANDEZFACILITY TYPE:
840
ADDRESS:8404 PHYLLIS PLACETELEPHONE:
(619) 746-9178
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 9DATE:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jocelyn HernandezTIME COMPLETED:
03:40 PM
NARRATIVE
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On 3/9/22 at 2:50 PM, Licensing Program Analyst (LPA) Keturah Lane conducted an unannounced case management visit to follow up on an unusual incident that occurred on 2/25/22 and was reported to duty line on 3/1/22. Upon arrival, LPA met with Site Director Jocelyn Hernandez and toured the facility. Census at time of visit was 9 children with staff members Verenice Olave and Director Hernandez present. LPA observed children inside room 102 doing activities and then transitioned to outside play. Room 102 was not being used.

LPA spoke with Director Hernandez and confirmed that an unauthorized pickup of a child in care (C1) occurred on 2/25/22. The child’s father (A1) had called the Director to authorize his girlfriend to pick up the child, but it wasn’t authorized by the contract parent (A2). LPA Lane received unusual incident report (LIC624) from the facility on 3/10/22. LPA advised Director to obtain court orders and visitation schedules from the child’s parents.

Pursuant to Title 22 of the CA Code of Regulations, the following Type B deficiency was cited (refer to LIC809-D).

Exit interview conducted and report was reviewed with Director Hernandez. Notice of Site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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Document Has Been Signed on 03/10/2022 03:27 PM - It Cannot Be Edited


Created By: Keturah Lane On 03/10/2022 at 03:04 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: KCE CHAMPIONS LLC AT ELEVATE MIDDLE
FACILITY NUMBER: 376105060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2022
Section Cited
CCR
101223(a)(2)

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101223 - Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by…
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Director stated they have planned to check ID at pick-up time for the remainder of the school year. Director will also review pick-up protocols with all staff members, including reviewing children’s LIC700 forms to see who is authorized to pick up each child in care. Director will provide statement of what was reviewed with staff members and have them sign and date the document. Document will be provided to LPA Lane by 3/17/22 via e-mail: Keturah.Lane@dss.ca.gov
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Based upon Director statement, an unauthorized pickup of a child in care happened on 2/25/22 which is a potential health, safety and personal rights risk to 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:Monica Cuddy
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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