<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417593
Report Date: 07/07/2021
Date Signed: 07/07/2021 02:21:27 PM

Document Has Been Signed on 07/07/2021 02:21 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: 0CENSUS: 37DATE:
07/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Karen Erroa, DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/07/2021, Licensing Program Analyst (LPAs) Monique Ayala and Isabel Ortega conducted a case management inspection during a complaint investigation. Upon arrival LPAs were greeted by the director who guided LPAs on a tour of the facility. LPAs observed 37 children in care with 7 staff.
LPAs observed animal feces in the sandbox and brought it to the attention of the director. The feces were removed immediately and disposed of. Director stated that there is a maintenance personal that comes out daily to rake the sand at 5:30am prior to facility opening.

LPAs observed infant #1 sleeping on his stomach with a pacifier string attachment. LPAs informed staff #1 that infant #1 needed to turned on his back and asked staff #1 to remove pacifier string attachment. Upon infant #1 being turned on his back LPAs observed red marking on infants #1 left cheek from the pacifier string attachment. LPAs observed infants #1 file where it stated to have the pacifier string attachment removed during nap time.

Two Type A deficiencies will be cited under Title 22 Regulation code 101439.1(1)(A) for Infant Care Center Sleeping Equipment and 101429((2)(B)(3) Responsibility for Providing Care and Supervision for Infants, see LIC9099D Upon receipt of a type A deficiency the director shall post the report for 30 days in addition to the Notice of Site Visit & provide copies of the licensing report to parents/guardians of children in care at the facility.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 07/07/2021 02:21 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 07/07/2021 at 12:51 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KAI'S JUSTICE LEARNING ACADEMY
FACILITY NUMBER: 197417593

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2021
Section Cited
CCR
101439.1(1)(A)

1
2
3
4
5
6
7
Infant Care Center Sleeping Equipment: Pacifiers shall be allowed in the crib if the following provisions are in place: There shall not be anything attached to the pacifier. This requirement was not met as evidence by... Based on LPAs observations,
1
2
3
4
5
6
7
Director stated that an all staff meeting will be held for employees on 07/30/2021 to review safe sleep regulation for infants in care. Director will provide a sign in sheet for staff that attended the training and provide a copy to LPA Oretga. Infant #1's pacifier attachment was removed immediately
8
9
10
11
12
13
14
LPA's observed infant #1 sleeping with a pacifier attachment. This poses an immediate health and safety risk to children in care.
8
9
10
11
12
13
14
Type A
07/07/2021
Section Cited
CCR101429(2)(B)(3)

1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision for Infants: Sleeping infant(s) shall be directly observed by sight and sound at all times. Staff shall physically check on sleeping infant(s) every 15 minutes and document the following: Infants up to 12 months of age who are sleeping in a position other than on their back.
1
2
3
4
5
6
7
Director stated that an all staff meeting will be held for employeeson 07/30/2021 to review safe sleep regulation for infants in care. Director will provide a sign in sheet for staff that attended the training and provde a copy to LPA Oretga. Infant #1 was turned on his back.
8
9
10
11
12
13
14
This requirement was not met as evidence by... Based on observations LPAs observed infant #1 sleeping on his stomach. This poses an immediate health and safety risk to children in care.
8
9
10
11
12
13
14
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:Mariela Ramon
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021


LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ACADEMY
FACILITY NUMBER: 197417593
VISIT DATE: 07/07/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee will obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file.

A Type B deficiency will be cited under Title 22 Regulations code 101238.2(f), Outdoor Activity Space, see LIC9099D

An exit interview was conducted a copy of this report was provided to the director along with Notice of Site Visit and appeal rights.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/07/2021 02:21 PM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 07/07/2021 at 01:02 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KAI'S JUSTICE LEARNING ACADEMY
FACILITY NUMBER: 197417593

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2021
Section Cited
CCR
101238.2(f)

1
2
3
4
5
6
7
Outdoor Activity Space: Sandboxes shall be inspected daily and kept free of hazardous foreign materials. This requirement was not met as evidence by... Based on observations, LPAs observed animal feces in children's sandbox. This poses a potential health and safety risk for children in care.
1
2
3
4
5
6
7
Director stated once maintenance personal comes to rake the sandbox, director will do another walk through to ensure the sandboxes are clean of hazardous foreign materials.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Mariela Ramon
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021


LIC809 (FAS) - (06/04)
Page: 4 of 4