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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 334845644
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:24:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2023 and conducted by Evaluator Giselle Carbullido
PUBLIC
COMPLAINT CONTROL NUMBER: 09-CC-20230420163453
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:72CENSUS: 13DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sara Bray TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are not making sure the toys are properly cleaned
INVESTIGATION FINDINGS:
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On date and time listed above, Licensing Program Analyst (LPA) Giselle Carbullido arrived at the facility to conduct an unannounced inspection to deliver the findings of the above allegations. On 04/26/2023, an initial inspection was completed, interviews were conducted, and records were obtained. During this inspection, the LPA discussed the findings of the above allegations with Assistant, Sara Bray.

Staff are not making sure the toys are properly cleaned: It was alleged the blocks are dirty in Classroom 4. LPA interviewed six staff. Interviews reported toys are sanitized, washed in soapy water and rooms are cleaned daily.
During tour of facility on 4/26/23, at approximately 11:15AM, LPA took four photos of Legos and wood blocks, including the shelf where blocks are located. LPA observed debris and dark brown buildup of dirt located on the Legos, wooden blocks, and shelf. During visit on 05/19/23, LPA observed legos blocks still with debris.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 09-CC-20230420163453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 334845644
VISIT DATE: 05/19/2023
NARRATIVE
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Based on LPA’s observations and photos obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED per California Code of Regulations, Title 22, Division 12. See LIC9099D for cited deficiencies.
Appeal rights issued and discussed with Assistant 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 were provided to the Assistant, Sara Bray. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC FOR THREE YEARS
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 09-CC-20230420163453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 334845644
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2023
Section Cited
CCR
101238(a)
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101238(a) Buildings and Grounds (a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement is not met as evidenced by:
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Facility will submit pictures of cleaned toys (Legos, table, and blocks) in classroom 4 by POC due date 5/23/23.
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Based upon LPA observation and photos obtained on visits 04/26/23 and 05/19/23, the facility did not meet the section cited above in that toys have built up grime and dirt on them. This is 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.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5