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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417593
Report Date: 02/08/2022
Date Signed: 02/08/2022 03:45:31 PM

Document Has Been Signed on 02/08/2022 03:45 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:KAI'S JUSTICE LEARNING ACADEMYFACILITY NUMBER:
197417593
ADMINISTRATOR:ADAMS, ALLEAFACILITY TYPE:
850
ADDRESS:2739 W. AVENUE LTELEPHONE:
(661) 718-3614
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 77TOTAL ENROLLED CHILDREN: 77CENSUS: 40DATE:
02/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Allea Adams, AdministratorTIME COMPLETED:
03:55 PM
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Licensing Program Analyst’s (LPA) Justeene Tamayo and Leandra Dolliole met with facility administrator, Allea Adams for the purpose of following up on an Unusual Incident Report that occurred on 01/20/22 and was reported to the Department on January 20,2022. Upon arrival LPA’s observed 40 preschool children with 6 teachers and the Director.

The incident reported indicated on 01/20/22 at around 10:30AM Child # 1 scratched child # 2 on the arm and face due to child #2 having a toy that child #1 wanted.

Based on the information gathered from observations, record review and interviews conducted with the children additional follow up is needed.

Exit Interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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