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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700539
Report Date: 07/01/2024
Date Signed: 07/01/2024 12:43:02 PM

Document Has Been Signed on 07/01/2024 12:43 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CHAMPION RESIDENTIALFACILITY NUMBER:
392700539
ADMINISTRATOR/
DIRECTOR:		BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:481 SPRING RIVER CIRCLETELEPHONE:
(510) 815-8570
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 4CENSUS: 4DATE:
07/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:BOYD, JAMESHATIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident report received dated 07/1/2024 . LPA explained purpose of visit to the administrator and staff.

The report was regarding a the facilities air conditioning not working, the facility has purchased portable air conditioner units that are keeping the facility cooled between 72-75*F. If the facility is not able to maintain the temperature they will relocate the residents. All residents attend day program during the day. The air conditioner unit will be replaced on 07/02/2024.

Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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