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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417593
Report Date: 03/18/2022
Date Signed: 03/18/2022 01:45:42 PM

Document Has Been Signed on 03/18/2022 01:45 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: 39DATE:
03/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Allea AdamsTIME COMPLETED:
02:00 PM
NARRATIVE
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On March 18, 2022, Licensing Program Analyst (LPA) Justeene Tamayo met with Licensee, 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 observed 39 preschool children with 8 staff.

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

Based on the information gathered from interviews conducted with the Licensee, Director, children, staff and video footage obtained from the day of the incident, it was determined that there was a lack of supervision during the time of the incident. Staff that were interviewed did not see the incident happen at the time of occurrence. Video footage shows an altercation between child #1 and child #2 with no visual supervision from staff members present in the classroom. As a result of the incident, Child #1 inflicted 4 minor scratches on Child #2 arm and face.

A Type B citation is being issued. The facility is found to not be in compliance with Title 22 regulations.

Exit Interview conducted and a copy of this report was provided to Licensee, Allea Adams along with notice of site visit and appeal rights.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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Document Has Been Signed on 03/18/2022 01:45 PM - It Cannot Be Edited


Created By: Justeene Tamayo On 03/18/2022 at 01:33 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: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision...No child(ren) shall be left without the supervision of a teacher at any time except...This requirement was not met as evidenced by:
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Per licensee she will talk to her staff and have an all staff meeting tomorrow 03/19/22 at 7 AM about care and supervision. LPA advised administrator to email a copy of sign in sheet no later than 03/25/22.
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Based on observation the video footage from the day of the incident demonstrates a lack of supervision from four teachers in the classroom. C2 approached C1 and C1 scratched C2 on the arm and face. This poses a potential health and 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:Mariela Ramon
LICENSING EVALUATOR NAME:Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
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