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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845644
Report Date: 10/14/2022
Date Signed: 10/14/2022 04:36:55 PM

Document Has Been Signed on 10/14/2022 04:36 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:
334845644
ADMINISTRATOR:KAREN BRAZZILLFACILITY TYPE:
850
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 15DATE:
10/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Karen BrazzillTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/14/22 at 3:30 PM a case management visit was completed by Licensing Program Analyst, (LPA), Giselle Carbullido due to deficiencies found during the course of another inspection.

1) Criminal Record Clearance: At 1pm, LPA observed one un-associated adult working at the facility without clearance or completion of exemption transfer.

SEE LIC 809-D for the deficiency cited. A civil penalty has been assessed.

LPA, Giselle Carbullido informed Director, Karen Brazzill that this report dated 10/14/22 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Giselle Carbullido informed the Director, Karen Brazzill to provide a copy of this licensing report dated 10/14/2022 that documents any Type A citation(s) 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, Karen Brazzill. LPA observed the Notice of Site Visit form was posted by staff. 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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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 10/14/2022 04:36 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 10/14/2022 at 03:33 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: 334845644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2022
Section Cited
CCR
101170(e)(1)

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101170(e) (1)- Criminal Record Clearance
(1) Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement is not met as evidenced by:
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Facility Director will submit statement of understanding of section 101170(e)(1) and of removal of S2 until clearance requirements are completed. Facility Director agrees to provide this report, cited deficiency issued by the department to the parent(s) of children in care within
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Based on LPA record review the facility did not obtain clearance nor complete exemption transfer for S2 prior to working at facility. LPA observed S2 working at facility during this visit. This poses an immediate health and safety risk to children in care.
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24 hours or the next time in care; this includes all newly enrolled children over the next 12 months. Facility Director agrees to submit proof of the signed acknowledgment(s) (LIC9224) to the department by 10/15/22 (10/17/22 due to weekend)

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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: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022


LIC809 (FAS) - (06/04)
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