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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700825
Report Date: 04/06/2023
Date Signed: 04/06/2023 03:36:38 PM

Document Has Been Signed on 04/06/2023 03:36 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CHAMPION RESIDENTIAL IIFACILITY NUMBER:
392700825
ADMINISTRATOR:BOYD, JAMESHAFACILITY TYPE:
735
ADDRESS:577 SUTHERLAND DR.TELEPHONE:
(209) 420-9932
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 4CENSUS: 4DATE:
04/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to the facility on 4-6-23 at 3:00pm. LPA met with lead caregiver Lucy Vanhsy and explained the purpose of the visit. LPA spoke with Administrator Jamesha Boyd via phone and explained the purpose of the visit, and Jamesha gave permission for Lucy to sign in her absence.

An exclusion action accusation was served to Staff 1 (S1) on 3-1-23. The Decision and Order was ordered on 3-27-23 and became effective 4-6-23. S1 is "prohibited from employment in, presence in, and contact with clients of, any facility licensed by the Department, certified or approved by a licensed foster family agency, or any resource family home, and is also prohibited from holding the position of member of the board of directors, executive director, or officer of the licensee of any facility licensed by the Department, for the remainder of S1’s life.” “Because S1 is specifically excluded from any care facility licensed by the Department in the above order, pursuant to Health and Safety Code section 1558 and Welfare and Institutions Code section 16519.6(g), S1 is excluded from all care facilities licensed by the Department…”

According to records and interview with Administrator, S1 was employed from 1/25/22 to 5/1/22. S1 resigned, and staff are unsure of the person's whereabouts. An updated LIC 500 form was obtained during today’s visit which did not reflect S1’s employment or presence in facility. Decision and Order document was provided and secured in Administrator's lock box upon LPA's departure.

No deficiencies observed. An exit interview was held with , and a copy of this report was provided as well as a copy of the Decision and Order for Licensee files.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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