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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418426
Report Date: 11/15/2021
Date Signed: 11/15/2021 01:16:12 PM

Document Has Been Signed on 11/15/2021 01:16 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: DATE:
11/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Allea Adams, LicenseeTIME COMPLETED:
01:33 PM
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Licensing Program Analyst (LPA) King-Lewis met with licensee Allea Adams for the purpose of conducting a Case Management inspection. On 08-20-21 child 1 was observed by staff 1 and staff 2 with an injury on child 1 back and arm pit. According to staff when an injury is observed the center will complete an injury report and notify the parent by text or in person. Staff did not follow the center policy procedures and the facility failed to notify the authorized representative (parent) of staff observations of child 1 injury on 08-20-21.

The facility was not in compliance per Title 22 regulations, a Type B deficiency will be cited today. Please see LIC809D for citation assessed.

An exit interview was conducted with licensee and appeal rights were discussed and provided. Notice of Site Visit posted. Failure to maintain posted for 30 Days will result in an immediate civil penalty.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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 11/15/2021 01:16 PM - It Cannot Be Edited


Created By: Lady King On 11/15/2021 at 12:35 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: 197418426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2021
Section Cited
CCR
101226.3(b)

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Any unusual behavior, any injury or signs of illness requiring assessment and/or administration of first aid by staff shall be reported to the child's authorized representative and recorded in the child's record. This requirement was not met by evidence, on 08-20-21 child 1 was
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Licensee stated training with staff was conducted on 11-05-21 for situations of reporting Injury timely to authorized representative and to the department. Licensee shall provide the department the training materials and sign in sheets by 11-25-21.
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observed by staff 1 and 2 with an injury to back and under arm pit. Staff failed to notify the parent in person or by text messaging. Staff admitted the facility did not provide parent with any type of notification on the observed injury on the day the injury was observed.
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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: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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