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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376105090
Report Date: 03/27/2024
Date Signed: 03/27/2024 05:23:48 PM

Document Has Been Signed on 03/27/2024 05:23 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
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KCE CHAMPIONS LLC AT INNOVATIONS ACADEMYFACILITY NUMBER:
376105090
ADMINISTRATOR:MADISON WALLERFACILITY TYPE:
840
ADDRESS:5454 RUFFIN ROADTELEPHONE:
(971) 378-2516
CITY:SAN DIEGOSTATE: CAZIP CODE:
92123
CAPACITY: 160TOTAL ENROLLED CHILDREN: 160CENSUS: 36DATE:
03/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Sara DeVitoTIME COMPLETED:
05:35 PM
NARRATIVE
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On 3/27/24 at 4:30 PM, Licensing Program Analyst (LPA) Keturah Lane conducted an unannounced case management visit to follow up on an unusual incident that occurred on 12/6/23 at the facility. A child (C1) was injured while playing with plastic bats on the playground. According to previous director Madison Waller she left a message on the duty line on 12/22/23 regarding the unusual incident but did not leave enough information on the message for the duty officer to complete the report. Director Madison Waller stated on the message that she would e-mail the report. Duty officer received a call back on 12/26/23 from Director Madison Waller. She stated the child received medical treatment and returned to care the following day on 12/7/23.

LPA Lane followed up with the facility on 1/19/24 and talked with new site director Sara DeVito. She stated that Madison Waller no longer works at the facility and she is the new site director. No director packet or notification until that date was received from the facility. Sara stated she became acting site director for the facility on 1/4/24. Also, department still had not received the unusual incident report from the facility. LPA advised Sara DeVito to submit the unusual incident report as soon as possible. It was received on 1/20/24 and dated 12/22/23. LPA advised Sara Devito that incident should be reported to the duty line within 24 hours and the written report submitted within 7 days. A Type B deficiency will be cited for not meeting these reporting requirements for unusual incidents. Also, a Type B deficiency will be cited for not submitting the information regarding a new director (and director's packet) within 10 days of the change. See LIC809-D for Type B deficiencies cited.

Exit interview conducted and report was reviewed with the facility representative site director Sara DeVito. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Keturah Lane
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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 03/27/2024 05:23 PM - It Cannot Be Edited


Created By: Keturah Lane On 03/27/2024 at 04:45 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 INNOVATIONS ACADEMY
FACILITY NUMBER: 376105090

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2024
Section Cited
CCR
101212(d)(1)(B)

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101212 Reporting Requirements (d)Upon the occurrence...a report shall be made to the Department by telephone or fax within the Department's next working day...In addition, a written report...shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include the following: (B) Any injury to any child that requires medical treatment. This requirement was not met as evidenced by...
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Site Director Sara DeVito submitted the UIR report to LPA Lane via e-mail on 1/20/24. LPA requested a written statement from Director stating she understands the reporting requirements to keep it from occurring in the future.
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Based upon documents received from the facility, duty call records and interviews with current site director, the unusual incident report was not reported according to requirements above which is a potential health, safety and personal rights risk to children in care.
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Type B
04/12/2024
Section Cited
CCR101212(b)

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101212 Reporting Requirements (b)The name of the child care center director...shall be reported to the Department within 10 days of a change of child care center director or designee(s). This requirement was not met as evidenced by...
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Site Director stated she would send the completed Director packet to LPA Lane by 4/12/24.
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Based upon interview with current site director the department was not notified of the change in director until LPA called to follow up on the UIR which was 1/19/24 which was more than 10 days after Sara Devito became Site Director 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:Tashima Daniel
LICENSING EVALUATOR NAME:Keturah Lane
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
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