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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845645
Report Date: 11/28/2022
Date Signed: 11/28/2022 04:02:42 PM

Document Has Been Signed on 11/28/2022 04:02 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: 20DATE:
11/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:19 PM
MET WITH:Karen Brazzill, DirectorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 11/28/22 at 3:19 PM, a case management visit was completed by Licensing Program Analyst (LPA) Giselle Carbullido due to deficiencies found during the course of another inspection.

Ratio: At 3:15PM during tour of facility, LPA observed one staff to 20 children in care in the school age program due to a 2nd staff leaving off site to pick up additional children. Director acknowledged ratio status during this visit.


SEE LIC 809-D for the deficiency cited.

LPA Carbullido informed Ms. Brazzill this report documents one Type A citation, which shall be posted for 30 consecutive days, as there was an immediate risk to the health, safety, or personal rights of children in care.

LPA Carbullido informed Ms. Brazzill to provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day, or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The Director was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted; a copy of this report and Notice of Site Visit was provided to the Director. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC UPON REQUEST FOR THREE YEARS.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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 11/28/2022 04:02 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 11/28/2022 at 03:32 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: 11/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2022
Section Cited
CCR
101516.5(b)(1)

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101516.5(b)(1) Teacher- Child ratio: (1) A teacher shall supervise no more than 14 children or with an aide a maximum of 28 children.

This requirement is not met as evidenced by:
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Facility will submit staff schedule showing staff coverage during school age pick ups and a letter stating understanding of regulation 101516.5 (b) (1) and how the teacher-child ratio will be met. Facility will submit proof of completion of LIC 9224 for all children enrolled in school age program.
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Based on LPA observation and Director acknowledgement, the facility did not meet the section above and operated out of ratio during transport for school age pick up. This poses an immediate health and safety risk to persons 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.
SUPERVISOR'S NAME:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022


LIC809 (FAS) - (06/04)
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