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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845645
Report Date: 01/05/2023
Date Signed: 01/05/2023 02:29:26 PM

Document Has Been Signed on 01/05/2023 02:29 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: 13DATE:
01/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Karen BrazzillTIME COMPLETED:
02:40 PM
NARRATIVE
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On this date and time, Licensing Program Analyst (LPA) Laura Mejorado arrived at the facility to conduct an inspection regarding a separate matter. During the course of the inspection LPA observed the facilities three vans which are used for transporting the school age children did not have the facility number. The three vans have the facility logo with the facilities name, programs offered and the facilities phone number. LPA also observed facility brochures in the front office which did not contain the facility number.

See LIC809D for cited deficiency of the California Code of Regulations, Title 22.


Exit interview conducted and report was reviewed with Director Karen Brazzill.

A notice of site visit was given and must remain posted for 30 days.

A copy of this report must be made available to the public, at the facility site, for 3 years.

SUPERVISORS NAME: Kimberly Williams
LICENSING EVALUATOR NAME: Laura Mejorado
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2023
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 01/05/2023 02:29 PM - It Cannot Be Edited


Created By: Laura Mejorado On 01/05/2023 at 01:57 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: 01/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
101162(a)(1)

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101162(a)(1) Licensees shall reveal each child care center license number in all advertisements in accordance with Health and Safety Code Section 1596.861. This requirement is not met as evidenced by:
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Director agrees to included facility number on the advertisements on the three vehicles used for transportation and the facility brochures and submit proof to CCL by 2/3/23.
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Based on LPA observations, the facility did not meet the section above and did not include their facility number on the advertisement's on the three vehicles used for transporting the school age children nor the facility brochures which were located in the front office, which poses a potential 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:Kimberly Williams
LICENSING EVALUATOR NAME:Laura Mejorado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2023


LIC809 (FAS) - (06/04)
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