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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197418426
Report Date: 10/15/2021
Date Signed: 10/15/2021 08:42:38 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2021 and conducted by Evaluator Lady King
COMPLAINT CONTROL NUMBER: 12-CC-20210823121449
FACILITY NAME:KAI'S JUSTICE LEARNING ACADEMYFACILITY NUMBER:
197418426
ADMINISTRATOR:TOLLIVER, ADRIENNEFACILITY TYPE:
830
ADDRESS:2739 W. AVENUE LTELEPHONE:
(661) 718-3614
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:10CENSUS: 4DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH: ALLEA ADAMSTIME COMPLETED:
09:00 AM
ALLEGATION(S):
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9

Daycare child sustained unexplained injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lady King-Lewis conducted a subsequent investigation inspection for the purpose of delivering the finding on the above allegation. Upon arrival, LPA was greeted by Licensee Allea Adams.. At the time of this inspection there were 4 infants in care.

The investigation consisted of interviews with Licensee’s assistants, the complainant and other pertinent parties. The investigation revealed the following:

Child 1 sustained an injury; the Department could not determine how the child sustained the scratch on back and under arm pit. Staff is denying the injury happen at the day care center. LPA toured the infant center and did not observe any item that may have caused the scratches on the child. Based on the preponderance of the evidence, the above allegation has been deemed to be unsubstantiated at this time. If the Department obtains additional evidence to support the above allegation, the complaint will be reopened.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 12-CC-20210823121449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 197418426
VISIT DATE: 10/15/2021
NARRATIVE
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An exit interview was conducted with licensee’s assistant, a copy of this report was provided along with the appeal rights and Notice of Site Visit.

An exit interview was conducted with licensee’s assistant, a copy of this report was provided along with the appeal rights and Notice of Site Visit.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2