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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418426
Report Date: 09/08/2022
Date Signed: 09/08/2022 12:23:39 PM

Document Has Been Signed on 09/08/2022 12:23 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:
197418426
ADMINISTRATOR:TOLLIVER, ADRIENNEFACILITY TYPE:
830
ADDRESS:2739 W. AVENUE LTELEPHONE:
(661) 718-3614
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 10TOTAL ENROLLED CHILDREN: 10CENSUS: 3DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Adrienne Tolliver, DirectorTIME COMPLETED:
12:30 PM
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On 09/08/22, Licensing Program Analyst (LPA) Justeene Tamayo met with the facility Director, Adrienne Tolliver for the One Year Required inspection for the infant license in accordance with the facility sketch. A tour of the facility was conducted. Upon arrival LPA observed 1 infant classroom in use with a total of 3 infants. There was 1 teacher on the premises and the Director. The hours of operation are 5AM-8PM Monday-Friday. Incidental Medical Services (IMS) were discussed.

During the tour of the facility, LPA observed adult #1 in the facility without a fingerprint clearance.This poses an immediate risk to children in care. Facility has been cited a Type A citation. Please see LIC809-D. A civil penalty of $500 dollars will be assessed.

Indoor/Children’s Area:
Child care center is clean, safe, sanitary and in good repair; all outdoor and indoor passageways, stair ways, incline, ramps, open porches and other areas of potential hazard are kept free of obstruction; floors of all rooms have a surface that is safe and clean, cleaning compounds inaccessible, poisons locked, furniture/equipment is good condition, free of flies, other insects, rodents; tables/chairs provided to meet children’s needs; all play equipment and materials used by children are age-appropriate, each child has an individual permanent or portable storage space (cubby, individually labelled with name) for his/her clothing, personal belongings and or bedding (stored separately). There is a working telephone.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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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: 197418426
VISIT DATE: 09/08/2022
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Children are inspected for illnesses (wellness policy) as they arrive. A review of medication policy indicated that prescription medication is administered only with parent's written permission (licensing medication form- LIC9221 - also used). Per Director, she does not have children enrolled who require medication. LPA advised the Director must administer medication, and document the dosage, date and time onto a log. Medication can be brought and taken home by the parent daily. Medication will be properly labeled and stored in its original container. There is a separate area for isolation and care of ill children in the therapy room

This facility provides Incidental Medical Services – IMS. Currently no IMS.
LPAs reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childquanda.htm

Food Service: There is a clean, fully equipped kitchen with refrigerator/freezer and microwave. The facility currently has a food program. Meals such as breakfast, lunch, and snacks and dinner are provided. LPA also observed a refrigerator in the infants classroom for infants formula and feeding bottles.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2022 12:23 PM - It Cannot Be Edited


Created By: Justeene Tamayo On 09/08/2022 at 11:55 AM
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: 197418426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Per Director, she cannot find the documentation of the last fire/disaster drill, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Director will complete a current fire/disaster drill and send to LPA Tamayo for proof of completion no later than 09/29/22.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. After file review, it was determined staff #1 did not have pertussis, measles, and influenza in her file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2022
Plan of Correction
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Director will submit proof of vaccinations to LPA Tamayo no later than 09/29/22.
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: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022


LIC809 (FAS) - (06/04)
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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: 197418426
VISIT DATE: 09/08/2022
NARRATIVE
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Staff/Personnel Records: Director (qualified) qualifications were verified, Designation of Responsibility observed, immunization's, TB clearance, health screening, criminal record statement, statement acknowledging suspected child abuse and mandated reporter were observed in file.

During file review, it was determined staff #2 did not have current vaccinations in the staff file. This poses a potential risk to children in care. Facility has been cited a Type B Citation. Please see LIC809-D.

Facility Records: Per Director, the last Fire/Disaster drill was completed in June of 2022. The Director could not find the written document of the last fire/disaster drill that was conducted. LPA reminded the Director, each Fire/Disaster Drill must be completed every 6 months, including proof of documentation of the date and time the last Fire/Disaster Drill was completed. Facility has been cited a Type B Citation. Please See LIC 809-D.

CPR/First Aid, and mandated report training were reviewed.

Posting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty.The following were observed posted as required: facility license, Personal Rights (LIC613A), Parent’s Rights Poster (PUB 394L), emergency disaster plan, earthquake preparedness checklist.

Documents Provided and or Discussed: Forms and records to keep at the facility and IMS.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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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: 197418426
VISIT DATE: 09/08/2022
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Advisory/Other: First Aid kit was observed with supplies (thermometer) readily available. Staff #1 CPR/First Aid expires on 09/12/2022. Director's Mandated Reporter Training expires on 06/30/2023.

Electrical outlets are inaccessible, recalled and or prohibited toys or sleep/play equipment were observed on the premises. There are no window cords accessible to children.

Sign in and out sheets were reviewed. The parent board was reviewed and has all of the required forms posted. Roster current. Director advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. Director shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of child care center or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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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: 197418426
VISIT DATE: 09/08/2022
NARRATIVE
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Trash cans for solid waste have tight fitting lids, drinking water is readily available indoors and outdoors (Drinking water is available inside the classrooms in the form of a water filter to fill up each child's water bottle). LPAs observed a sufficient quantity of cribs available for napping infants. All materials and surfaces are toxic free are inaccessible, no fireplace. There is a working Carbon monoxide detector, smoke detector and Fire Extinguisher (2A10BC).

Restrooms: LPA inspected and observed one changing table, as well as clean diapers readily available. LPAs observed soap, toilet paper and paper towels readily available. Water temperature is appropriate. There is an isolation area for children who become ill while in care located in the therapy room, facility maintains a comfortable temperature at all times, first aid supplies (thermometer, bandages, scissors), sign in/out sheets (electronically) available and completed daily. No Smoking prohibited on the premises, daily inspection for illness, no prohibited child care items observed. Firearms/weapons are not allowed or stored on premises. There is no body of water on the premises.

Napping: LPA observed children's personal sheets in each cubby. Cribs used are maintained in good condition, wiped/cleaned/disinfected (daily) weekly or when soiled, no contact with other children bedding. LPA observed a tight fitted sheet in each crib.

Outdoor: Per director, the infants usually stay in the center and do not have an outdoor play area.

Teacher child ratios were observed and staff name recorded. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate.

Health Related Services: Medications inaccessible to children; all prescription and non-prescription medications have child’s name and are dated; written consent and instruction from child’s representative, a plan to document and report to child’s representative when medication is administered to a child; IMS plan on file (if applicable).
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 09/08/2022 12:23 PM - It Cannot Be Edited


Created By: Justeene Tamayo On 09/08/2022 at 11:55 AM
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: 197418426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA observed adult #1 in the facility without a fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2022
Plan of Correction
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LPA observed adult #1 leave the facility. Per director she will have adult #1 submit required documentation to DOJ.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022


LIC809 (FAS) - (06/04)
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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: 197418426
VISIT DATE: 09/08/2022
NARRATIVE
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process


A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
No deficiency. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.

Exit interview conducted and report was reviewed with Director Adrienne Tolliver. This report was read and provided to Director Adrienne Tolliver, along with her appeal rights.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Justeene Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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