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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845644
Report Date: 12/28/2023
Date Signed: 12/28/2023 12:29:24 PM

Document Has Been Signed on 12/28/2023 12:29 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:
334845644
ADMINISTRATOR:KAREN BRAZZILLFACILITY TYPE:
850
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 21DATE:
12/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Karen BrazzillTIME COMPLETED:
12:30 PM
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 An unannounced case management inspection was conducted by Licensing Program Analyst (LPA) Blanca Ruiz. LPA met with Facility Director, Karen Brazzill. The center was toured and a census was taken. The purpose of the inspection was to deliver amended page(s) of LIC 9099.

No deficiencies were cited during inspection.

An exit interview conducted and report was review with Facility Director, Karen Brazzill. A copy of this report was provided to the director on this date and must be made available to the public upon request for the next 3 years.

A notice of site visit was given and must remain posted immediately adjacent to,the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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