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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419528
Report Date: 09/10/2021
Date Signed: 09/10/2021 11:25:55 AM

Document Has Been Signed on 09/10/2021 11:25 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:JUS KIDS ACADEMYFACILITY NUMBER:
197419528
ADMINISTRATOR:VITELA, MARIANAFACILITY TYPE:
850
ADDRESS:11211 WESTERN AVETELEPHONE:
(323) 777-0704
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 29TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
09/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Margaret PettisTIME COMPLETED:
11:30 AM
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On 9/10/2021, Licensing Program Analyst (LPA) Lillian Casillas conducted a Case Management - Deficiencies Inspection. LPA met with Licensee, Margaret Pettis, and discussed the purpose of the visit.

During the inspection, LPA interviewed 3 children and 3 staff and obtained copies of the following documents: sign-in/sign-out sheets for 9/10/2021 and 8/30-9/9/2021, staff contact information and schedule, and the LIC 308 Designation of Facility Responsibility. Licensee agreed to send up-to-date LIC 9040 Child Care Facility Roster by 9/17/2021.

Based on record review, LPA issued a (LIC 9102TA) Advisory Notes - Technical Assistance to the Licensee to offer consultation on sign in/out sheets pursuant to Title 22 Regulation 101229.1 (a)(1).

An exit interview was conducted and a copy of this report along with the Notice of Site Visit were provided to Licensee.
SUPERVISORS NAME: Maureen Neal
LICENSING EVALUATOR NAME: Lillian J Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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