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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417593
Report Date: 04/26/2022
Date Signed: 05/03/2022 11:33:06 AM

Document Has Been Signed on 05/03/2022 11:33 AM - 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: 33DATE:
04/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Adrienne Tolliver, DirectorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPA’s), Justeene Tamayo and Justin Dorsey conducted a case management incident visit on 04/26/22. LPA’s met with Director Adrienne Tolliver for the purpose of addressing an unusual incident that occurred at the facility on 04/12/2022 and was not reported to CCLD. After interview and file review, LPA’s confirmed that there was a total of two children who have been diagnosed with Hand, Foot, and Mouth Disease between the dates of 04/12/2022 to 04/19/2022. During inspection, Director Allea Adams came shortly after.

Per Director Allea Adams, she did not know that child #2 was diagnosed with Hand, Foot, and Mouth Disease. LPA Tamayo advised Director Allea Adams to immediately call the Department of Public Health as of yesterday 04/25/2022. The licensee shall report to the local health officer all outbreaks or suspected outbreaks involving two or more children of any communicable disease.

The staff were given specific instructions by the health department to continue monitoring all children in care and report to health department if more cases of HFM outbreak occur. Center staff cleaned and disinfected the toys, napping equipment, tables, chairs, floors, stuff animals, that meet the health department requirement standard. According to Director Adams, all parents were individually informed. A letter of exposure was provided to all parents. LPA’s obtained children's documents. Per director she was unable to contact Department of Public Health but will email them about the outbreak and forward to LPA Tamayo.

A type B citation was issued and provided to Director Allea Adams, along with a Notice of Site Visit and Appeal Rights.

An exit interview was conducted. A copy of this report was provided and given to Director Allea Adams.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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 05/03/2022 11:33 AM - It Cannot Be Edited


Created By: Justeene Tamayo On 04/26/2022 at 03:11 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: 04/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2022
Section Cited
CCR
101212(d)(1)(e)

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101212 (d)(1)(e) Upon the occurrence...a report shall be made to the Department by telephone or fax within the Department's next working day...a written report...shall be submitted within seven days following the occurrence of such event. Events reported shall include the following: Epidemic outbreaks. This requirement is not met as evidenced by.
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Director will send LIC624 to LPA no later than today 04/26/2022.
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Based on observation, interview, and record review, Licensee did not notify the Department of the incident that occurred on 04/11/2022 within the time frame required. This is a type B deficiency...which can pose 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: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022


LIC809 (FAS) - (06/04)
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