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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617614
Report Date: 06/27/2024
Date Signed: 06/27/2024 01:29:39 PM

Document Has Been Signed on 06/27/2024 01:29 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CHAMPIONS @ CARROLL ELEMENTARYFACILITY NUMBER:
343617614
ADMINISTRATOR/
DIRECTOR:		DONYEALL ROBINSONFACILITY TYPE:
850
ADDRESS:10325 STATHOS DRIVETELEPHONE:
(916) 714-4362
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 21TOTAL ENROLLED CHILDREN: 21CENSUS: 21DATE:
06/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Donyeall RobinsonTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 06/27/2024, Licensing Program Analyst (LPA) Corina Beckby conducted a field visit to the facility for the purpose of a case management inspection. LPA arrived at the center and was met by Site Director (SD), Donyeall Robinson and disclosed purpose of visit. LPA observed 1 Teacher and 2 assistants supervising 21 students. LPA conducted a tour of the facility and observed a bottle of Lysol bleach on the bottom shelf, accessible to the children. The bottle was inside a large, unlocked closet/cabinet inside the children’s bathroom.

LPA informed Site Director, Donyeall Robinson that this report dated 06/27/2024, documents a Type A citation that is an immediate Health and Safety, or Personal Rights risk to persons in care. An 809D is issued for the deficiency.

Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed Acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

An Exit interview was conducted, and the report was reviewed with Site Director, Donyeall Robinson. LPA posted a notice of site visit. Licensee understands the notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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 06/27/2024 01:29 PM - It Cannot Be Edited


Created By: Corina Beckby On 06/27/2024 at 12:48 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CHAMPIONS @ CARROLL ELEMENTARY
FACILITY NUMBER: 343617614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2024
Section Cited
CCR
101238(g)

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Buildings and grounds 101238(g): Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
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SD will remove all cleaning products and place them in a locked upper cabinet, making it inaccessible to children SD will train staff to properly store cleaning agents that are an immediate risk to the children.
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LPA observed cleaning solutions in an unlocked cabinet in the children's bathroom, accessible to children.
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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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
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