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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419412
Report Date: 12/30/2021
Date Signed: 12/30/2021 12:41:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:KAI'S JUSTICE CHILDCARE CENTERFACILITY NUMBER:
197419412
ADMINISTRATOR:JONES, AKEMIEFACILITY TYPE:
840
ADDRESS:2307 E. PALMDALE BLVD.TELEPHONE:
(661) 947-5247
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:54CENSUS: DATE:
12/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Allea AdamsTIME COMPLETED:
01:00 PM
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On 12-30-21, Licensing Program Analysts (LPA) Lady King-Lewis conducted a Case Management Inspection at the Lancaster facility for the purpose of delivering an Immediate Exclusion Order for staff Maya Samura. Upon arrival LPA met with licensee, Allea Adams. During this inspection, Maya Samura was not present.

The California Department of Social Services (CDSS) has determined that Maya Samura continued or future contact with clients or presence in any community care facility, child day care facility, residential care facility for the elderly, or any other facility licensed by CDSS, constitutes a threat to the health, welfare or safety of the clients in care.

Upon receipt of the immediate exclusion order, Maya Samura, must remove herself from any contact with clients and not be physically present in any facility. This action is final until Maya Samura is notified otherwise, in writing by CDSS.

The order to immediately exclude Maya Samura was discussed in detail with licensee Allea Adams. Licensee is aware that Maya Samura must not be physically present in the facility nor can she have contact with children in care. Licensee Allea Adams acknowledges the receipt of the Immediate Exclusion Order served today.

An exit interview was conducted with Allea Adams and a copy of this report was provided along with the appeal rights.
SUPERVISOR'S NAME: Mariela RamonTELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady KingTELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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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