376105060-6-13-2023-51-CC-KLAE-CSRTTC-20230613150028

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376105060
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:00:38 PM

Document Has Been Signed on 06/13/2023 03:00 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 MIDDLE		FACILITY NUMBER:	376105060
ADMINISTRATOR:	JASMINE NELSON		FACILITY TYPE:	840
ADDRESS:	8404 PHYLLIS PLACE		TELEPHONE:	(619) 746-9178
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92123
CAPACITY: 50	TOTAL ENROLLED CHILDREN: 50	CENSUS: 2	DATE:	06/13/2023
TYPE OF VISIT:	Case Management - Lead Testing/Exceedance	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jocelyn De La Riva		TIME COMPLETED:	03:30 PM

NARRATIVE

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On 6/13/23 at 2:30 PM, Licensing Program Analyst (LPA) Keturah Lane conducted an unannounced case management inspection at the facility for the purpose of following up on a lead exceedance reported in Room 102 (outlet “D”). Upon arrival, LPA met with interim site director Jocelyn De La Riva and toured the facility. LPA observed a total of 2 children in room 205 with staff members Atefeh Forouhar and Site Director Jocelyn De La Riva. Room 101 was not available to observe. LPA observed room 102 (not in use) and found sink (outlet “D”) did not have sign posted nor was the sink covered. Sink was operational...however, facility is not using room 102. LPA advised site director regarding the sink is not inaccessible. Site director stated they have notified the school officials regarding the lead exceedance. LPA advised one of the school officials regarding the lead exceedance and provided technical assistance. Today is the last day of school at the facility and it will be closed until mid August 2023.

Fixtures were sampled for lead in the licensed rooms 101, 102 and 205 on 5/17/23. A lead exceedance of 7.08 ppb was reported in room 102 (outlet “D”) and received on 5/30/23. LPA received via e-mail the report, sketch, photos and plan of correction from Champions Area Manager Danielle Cavanaugh on 6/9/23. Additional documents were received on 6/13/23.

Facility is currently not using rooms 101 and 102, however wishes to keep them on the license at this time. Room 102 was last used by the facility on 2/10/23. Facility is now using room 205 for the after-school program. Facility starting using bottle water exclusively when children returned from winter break on 1/3/23.

See LIC809-D for Type B deficiency cited. A proof of correction clearance letter was provided. Exit interview conducted and report was reviewed with interim site director Jocelyn De La Riva. Notice of Site Visit was provided and must remain posted for 30 days.

SUPERVISORS NAME: Monica Cuddy
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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 06/13/2023 03:00 PM - It Cannot Be Edited

Created By: Keturah Lane On 06/13/2023 at 01:35 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: 06/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/13/2023 Section Cited CCR 101700.3(b)(2)	1 2 3 4 5 6 7	101700.3(b)(2) Licensees shall maintain a lead value at or below the Action Level of 5 ppb in all outlets subject to the testing requirements of these Written Directives, for the health and safety of children in care. This requirement was not met as evidenced by…	1 2 3 4 5 6 7	Director stated that the children have not be using room 102 since 2/13/23 and have been using bottled water for drinking and food prep since 1/3/23. Children will continue to be in room 205 which does not have a lead exceedance.
	8 9 10 11 12 13 14	Based on test results received on 5/30/23, licensee failed to maintain a lead value at or below the Action Level for water lead testing resulting with values of 5.5 ppb or greater for outlet “D” located in room 102 which tested at 7.08 ppb. Water testing results identified with Action Level Exceedance as defined in WD section 101700.3 are not deemed safe to drink and is a potential health, safety and personal rights risk to children in care.	8 9 10 11 12 13 14	Last day of school is 6/13/23 and children will return in mid-August 2023. A plan is in process with facility contractor for possible installation of replacement fixtures, reflushing and retesting before children return in August. Director stated she would submit the plan to LPA via e-mail prior to return of children to room 102.
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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: 06/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

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