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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701464
Report Date: 10/20/2023
Date Signed: 10/20/2023 08:29:36 AM

Document Has Been Signed on 10/20/2023 08:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MISSION VALLEY, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KCE CHAMPIONS LLC AT VILLAGE ELEMENTARYFACILITY NUMBER:
376701464
ADMINISTRATOR:ALEXIE GATESFACILITY TYPE:
840
ADDRESS:600 SIXTH STREETTELEPHONE:
(619) 865-1577
CITY:CORONADOSTATE: CAZIP CODE:
92118
CAPACITY: 196TOTAL ENROLLED CHILDREN: 196CENSUS: 3DATE:
10/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
06:30 AM
MET WITH:Ruby Carrasco, Facility RepresentativeTIME COMPLETED:
07:45 AM
NARRATIVE
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On 10/20/2023 at 6:30 am, Licensing Program Analyst (LPA), Michelle Hood, made an unannounced inspection to follow up on a self reported incident wherein a 8 year old child fell and landed on a sharp piece of metal that was accessible to child while playing on the playground. The child sustained a open cut which needed medical attention.

During today's inspection, the LPA and facility representative Ruby Carrasco observed the playground area where the child was injured. LPA observed the tether pole holes filled with cement and have been made inaccessible to children in care.

The incident occurred on 09/28/2023, and a report was not made to the Department by telephone, email or fax within the Department's next working day and during its normal business hours.

An exit interview was conducted and the report was reviewed with the facility representative Ruby Carrasco. Carrasco was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. See the 809D page for the deficiencies cited under regulation 101223(a)(2)- Personal Rights and 101212 (d)(1)(B) - Reporting Requirements
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Michelle Hood
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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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Document Has Been Signed on 10/20/2023 08:29 AM - It Cannot Be Edited


Created By: Michelle Hood On 10/20/2023 at 07:59 AM
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 VILLAGE ELEMENTARY
FACILITY NUMBER: 376701464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
CCR
101223(a)(2)

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101223 Personal Rights (a)(2) - The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirment was not met by:
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The director will provide the LPA a written plan on how staff will ensure the facility and playground is safe and free from hazards that can harm children in care. The director will reveiw the plan with the staff.
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The director and staff did not ensure the facility playground was safe and harzard free before allowing chidren to play on the facility playground. This is a potential health & safety risk to children in care.
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Type B
11/17/2023
Section Cited
CCR101212(d)(1)(B)

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101212 (d)(1)(B)- Reporting Requirements. Upon the occurrence, during the operation of the child care center of any of the events specified in below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours...Events reported shall include the following:Any injury to any child that requires medical treatment. This requirement was not met by:
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The diretcor will create a plan on how the facility plans to ensure Unusual Incidents are reported to the dept.
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The director did not contact the dept. within twenty-four hours from the date of injury or when medical treatment was assessed. This is a potential health & safety 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:Cynthia Gray
LICENSING EVALUATOR NAME:Michelle Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023


LIC809 (FAS) - (06/04)
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