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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417593
Report Date: 08/24/2021
Date Signed: 08/24/2021 05:37:25 PM

Document Has Been Signed on 08/24/2021 05:37 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: DATE:
08/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Akemie Jones Director over Palmdale CenterTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady King-Lewis conducted a Case Management inspection for the purpose to discuss the Department’s concern with the operation of the facility. Upon arrival, LPA was greeted by director Akemie Jones. LPA observed 10 children in care with 2 staff providing care and supervision.

The Department has learned that on 06/08/21, Licensee Allea Adam confronted a day child, staff and child’s parent concerning an alleged incident. Licensee’s actions and conduct were inappropriate.

Upon receipt of a Type A deficiency licensee 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. 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.



If these requirements are not met, civil penalties will be assessed.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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Document Has Been Signed on 08/24/2021 05:37 PM - It Cannot Be Edited


Created By: Lady King On 08/24/2021 at 05:11 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: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2021
Section Cited
HSC
1596.885(c)

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Conduct Inimical: Licensee Allea Adam engaged in conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California. This requirement was not met as evidence by on 06/08/21, Licensee Allea
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Licensee shall provide a written plan to the Department no later than 08/25/21 on how she would handle this type of incident appropriately.
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Adam confronted a day child, staff and child’s parent concerning an alleged incident. Licensee’s actions and conduct were inappropriate. This is a Type A violation and it poses an immediate risk to the health and safety of 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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021


LIC809 (FAS) - (06/04)
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