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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417593
Report Date: 06/08/2021
Date Signed: 06/08/2021 04:26:37 PM

Document Has Been Signed on 06/08/2021 04:26 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:KAI'S JUSTICE LEARNING ACADEMYFACILITY NUMBER:
197417593
ADMINISTRATOR:ADAMS, ALLEAFACILITY TYPE:
850
ADDRESS:2739 W. AVENUE LTELEPHONE:
(661) 718-3614
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 77TOTAL ENROLLED CHILDREN: 77CENSUS: 16DATE:
06/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:ALLEA ADAMSTIME COMPLETED:
04:36 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady King-Lewis conducted a Case Management inspection and discover the Licensee failed to report incidents to the department.

Prior to the visit LPA reviewed the FAS database and determined incident reports were not made by Licensee regarding incident that occurred at the facility.

Based on LPA observations, interviews conducted, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED.

California Code of Regulations, Title 22, Division 12 Chapter 1, 101212 (d) Reporting Requirements Type B violation is being cited on attached LIC 809 D.

Exit interview conducted and a copy of this report, Appeal Rights, notice of sight visit was provided to Licensee Allea Adams.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2021
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 2
Document Has Been Signed on 06/08/2021 04:26 PM - It Cannot Be Edited


Created By: Lady King On 06/08/2021 at 04:04 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: KAI'S JUSTICE LEARNING ACADEMY
FACILITY NUMBER: 197417593

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2021
Section Cited
CCR
101212(d)

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Reporting Requirements. A report shall be made to the Department by telephone or fax within the Department's next working day...a written report ... shall be submitted to the Department within seven days.

This requirement was not met as evidence by:
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Licensee agreed to submit the completed Unusual Incident Report (LIC624) detailing the incident by 06/09/21.
and
submit a written statement of how she will make sure the center is reporting incidents to the department by conducting training with staff by 06-15-21.
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Based on observation, interview, and record review, Licensee did not notify the Department of the incident within the time frame required, which poses a potential Health 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.
SUPERVISOR'S NAME:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2021


LIC809 (FAS) - (06/04)
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