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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 334845644
Report Date: 11/14/2022
Date Signed: 11/14/2022 05:10:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2022 and conducted by Evaluator Giselle Carbullido
PUBLIC
COMPLAINT CONTROL NUMBER: 09-CC-20221011141852
FACILITY NAME:KINGSTON ACADEMYFACILITY NUMBER:
334845644
ADMINISTRATOR:KAREN BRAZZILLFACILITY TYPE:
850
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY:72CENSUS: 27DATE:
11/14/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Karen BrazzillTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff have inadequate records
INVESTIGATION FINDINGS:
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On date listed above, Licensing Program Analyst (LPA) Giselle Carbullido arrived at the facility to conduct an unannounced inspection to deliver the findings of the above allegations. On 10/14/22 an initial inspection was completed; interviews were conducted, and records were obtained. During this inspection the LPA discussed the findings of the above allegations with the Director, Karen Brazzill.
Staff have inadequate records. It was reported files are not up to date.
LPA reviewed 5 staff files during the course of this investigation. File review revealed Non EMSA approved CPR/first aid and other missing staff documents of immunization, TB, employee rights, and health screen.
Based on staff file reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED per California Code of Regulations, Title 22, Division 12. See LIC9099D for cited deficiencies.
An exit interview was conducted, and appeal rights discussed. A copy of this report, Notice of Site Visit, and appeal rights were provided to Karen Brazzill. This report must be made available to the public upon request for three years.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
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 6
Control Number 09-CC-20221011141852
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KINGSTON ACADEMY
FACILITY NUMBER: 334845644
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited
CCR
101217(a)
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Personnel records: 101217(a)-The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidence by:

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Facility Director will submit proof of completion for employee records for S1, S2, and S5 to LPA Carbullido by POC due date of 11/21/22.
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Based on record review the facility did not meet the section above in that staff had missing: employee rights(S1); immunizations TB and health screen (S2) immunizations S5. This is a potential heath and safety risk to children in care.
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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.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2022 and conducted by Evaluator Giselle Carbullido
PUBLIC
COMPLAINT CONTROL NUMBER: 09-CC-20221011141852

FACILITY NAME:KINGSTON ACADEMYFACILITY NUMBER:
334845644
ADMINISTRATOR:KAREN BRAZZILLFACILITY TYPE:
850
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY:72CENSUS: DATE:
11/14/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Karen BrazzillTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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2
3
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9
Staff are operating out of ratio
INVESTIGATION FINDINGS:
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On date listed above, Licensing Program Analyst (LPA) Giselle Carbullido arrived at the facility to conduct an unannounced inspection to deliver the findings of the above allegations. On 10/14/22 an initial inspection was completed; interviews were conducted, and records were obtained. During this inspection the LPA discussed the findings of the above allegations with the Licensee, Karen Brazzill. Facility is operating out of ratio. It was reported that the facility is operating out of ratio.
LPA interviewed 4 staff and the Director.
Director interview stated the facility is not operating out of ratio. Director stated there is one staff for every 12 children. Director disclosed they create a waiting list for enrollment if needed to ensure staff to child ratio is met. During the course of interviews; staff identified the ratio as 1 staff to 12 children and denied being out of ratio. LPA observed staff time sheets and the number of children signed in. Attendance/time sheets sampled do not clearly identify staff to child ratios. During visits, LPA toured and observed the following ratios: on 10/14/22 1 staff to 10 children and on 11/14/22 2 staff to 14 children. LPA is unable to definitively identify if the facility was operating out of ratio.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 09-CC-20221011141852
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: KINGSTON ACADEMY
FACILITY NUMBER: 334845644
VISIT DATE: 11/14/2022
NARRATIVE
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Based on the evidence collected, there was not sufficient evidence to substantiate or refute the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted, a copy of this report and Notice of Site Visit was provided to the Director. LPA observed the Notice of Site Visit was posted by staff. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC FOR THREE YEARS

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6