<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845645
Report Date: 05/13/2022
Date Signed: 05/13/2022 01:34:43 PM

Document Has Been Signed on 05/13/2022 01:34 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:
334845645
ADMINISTRATOR:KAREN BRAZZILLFACILITY TYPE:
840
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 49TOTAL ENROLLED CHILDREN: 49CENSUS: 0DATE:
05/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Karen BrazzillTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/13/2022 at time listed above Licensing Program Analyst (LPA) Justin Giese made an unannounced visit to the Facility for another purpose. LPA met with Facility Director, Karen Brazzill.

At time of 12:00pm While conducting other matters LPA Giese was introduced to a new staff member Identified as Staff #1. Director stated Staff #1 was a new employee designated to the school age program as a bus driver, their primary roles is aiding the facility with after school pick ups and drop offs of school aged children. LPA was informed by Director Staff #1 was finger printed, cleared and associated to the facility. Upon review of staff records and facility staff associations, LPA noted that Staff #1 did not have proper fingerprint clearance and was pending association to the facility. The facility was found to be in violation of the following Title 22 regulation:

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...

See LIC809D for cited Type A deficiency

Director immediately removed Staff #1 from the facility after LPA reviewed Facility's Employee roster and associations.


Continued on LIC809C
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 334845645
VISIT DATE: 05/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A Civil Penalty of $500 will be assessed during this inspection for Staff Criminal Record Clearance.

Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”.

YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

LPA issued a Notice of Site Visit and verified it was posted in a prominent location at the facility. Licensees understands that the Notice of Site Visit must remain posted for the next 30 days along with a copy of all Type A deficiencies cited during this inspection. A copy of all Type A deficiencies cited during this inspection must also be immediately (within 24 hours of child’s next day in care) given to the parents of all children enrolled in the child care facility and any children enrolled into the child care facility over the next 12 months (at the time of enrollment). Licensees are required to have all parents sign and date the Acknowledgement of Receipt of Licensing Reports (LIC9224) and maintain a copy in each child’s file. A copy of this report, LIC9224 and Appeal Rights (LIC9058) were provided during this inspection.

Exit interview conducted and report was reviewed with the Facility representative, Karen Brazzill.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/13/2022 01:34 PM - It Cannot Be Edited


Created By: Justin Giese On 05/13/2022 at 01:07 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KINGSTON ACADEMY
FACILITY NUMBER: 334845645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2022
Section Cited
CCR
101170(e)(1)

1
2
3
4
5
6
7
Criminal Record Clearance. (e) All individuals subject to a criminal record review...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...
1
2
3
4
5
6
7
Director understands this violation and agrees to check all employee clearances with the Guardian and CCL regional office prior to the initial presence or start of work in the Facility.
A civil penalty of $500 has been assessed.
8
9
10
11
12
13
14
Based on records review, the licensee did not comply with the section cited above. Staff #1 did not have an active fingerprint clearance. This poses an immediate health, safety and personal rights risk to children in care. A Civil Penalty has been assessed.
8
9
10
11
12
13
14
Director immeditley removed Staff #1 from the facility at time of visit. Staff #1 will obtain propper clearance and association to facility before returning.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3