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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841006
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:57:10 PM

Document Has Been Signed on 04/17/2024 03:57 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CHAMPIONS AT MILLER MIDDLE SCHOOLFACILITY NUMBER:
334841006
ADMINISTRATOR/
DIRECTOR:		SADURA PATTONFACILITY TYPE:
840
ADDRESS:17925 KRAMERIA AVENUETELEPHONE:
(951) 789-8181
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 112TOTAL ENROLLED CHILDREN: 112CENSUS: 5DATE:
04/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Sadura Patton/Cammie DonaghyTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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A case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 04/12/24. It indicates a staff working alone did not meet personnel requirements.

Facility records were reviewed, and interviews conducted with pertinent parties.

Pertinent party interviews and record review confirmed a staff worked alone in the capacity of a director without meeting personnel requirements.

Based on the information gathered, the following violations have been identified: Facility did not have a qualified staff to cover during the absence of the director per CCR regulation- 101215.1(f) Child Care Center Directors Qualifications and Duties.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12.

An exit interview was conducted, and LPA Carbullido provided the Facility Representative with a copy of this report, appeal rights and notice of site visit during today’s visit.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 04/17/2024 03:57 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 04/17/2024 at 03:30 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHAMPIONS AT MILLER MIDDLE SCHOOL
FACILITY NUMBER: 334841006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2024
Section Cited
CCR
101215.1(f)

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CCC Directors Qualifications and Duties 101215.1(f) When director is absent … arrangements shall be made for a fully qualified teacher … to act as substitute. This substitute … shall be aware of center operations, … shall be designated as an authorized person to correct operational deficiencies … safety. This requirement is not met as evidenced by:

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Facility will submit a written plan outlining staff coverage in the absence of a facility Director, including a statement of understanding of CCR regulation 101215.1(f) by POC due date 04/22/24 or earlier.
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Based on interviews and record review, the licensee did not comply with the section cited above in that S2 worked in the capacity of a Director without meeting personnel requirements which poses/posed a potential health, safety or personal rights risk to persons 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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
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