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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845644
Report Date: 03/14/2022
Date Signed: 03/14/2022 12:23:10 PM

Document Has Been Signed on 03/14/2022 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KINGSTON ACADEMYFACILITY NUMBER:
334845644
ADMINISTRATOR:LIANG, HANBOFACILITY TYPE:
850
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 14DATE:
03/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
12:40 PM
NARRATIVE
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On 03/14/2022 Licensing Program Analyst (LPA) Justin Giese arrived at the facility at 10:30 am and met with Facility Director, Karen Brazzill.

Based on LPA’s observations, interviews and records reviewed, the facility had knowledge of an incident where a child had bit another child on 01/28/2022. Although the facility documented the incident on internal incident/accident forms, the facility did not report the incident to Licensing Office. Licensing was made aware of the incident while conducting an unannounced visit on 02/14/2022 for another purpose.

The facility has failed to meet their reporting requirements. This is a potential risk to the health and safety of children in care. See LIC809D for type B citation for Reporting Requirements.

An exit interview was conducted with Director Karen Brazzill

A NOTICE OF SITE VISIT WAS ISSUED AND LPA VERIFIED THAT IT WAS POSTED IN A PROMINENT LOCATION AT THE FACILITY BEFORE LEAVING. THE LICENSEE UNDERSTANDS THAT IT MUST REMAIN POSTED FOR THE NEXT 30 DAYS

Appeal rights were provided and discussed. This report must be available for review, upon request, for the next 3 years
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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 03/14/2022 12:23 PM - It Cannot Be Edited


Created By: Justin Giese On 03/14/2022 at 10:10 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KINGSTON ACADEMY
FACILITY NUMBER: 334845644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2022
Section Cited
CCR
101221(d)(1)(c)

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Reporting Requirements - Any unusual incident or child absence that threatens the physical or emotional health or safety of a child shall be reported to the Department within 24 hours of the occurrence.

This requirement has not been met as evidenced by:
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Facility Director understands the importance of reporting requirements and documentation of unusual incidents that occur in the facility. Facility Director will conduct training with staff and members of management on proper procedures for self-reporting and documenting unusual incidents that occur at the facility and the proper time frame they must be reported
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Based on interviews conducted with staff on 02/14/2022, LPA discovered the facility had knowledge of an unusual incident which occured on 01/28/22 regarding a day-care child biting another day-care child and failed to report it to Licensing. This poses a potential risk to the health and safety of children in care.
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to licensing. Documentation of training/proof of correction will need to be submitted to LPA on or before the date of correction, 03/21/2022

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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:Gilbert Sena
LICENSING EVALUATOR NAME:Justin Giese
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022


LIC809 (FAS) - (06/04)
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