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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845644
Report Date: 10/29/2024
Date Signed: 10/29/2024 09:26:56 AM

Document Has Been Signed on 10/29/2024 09:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:KINGSTON ACADEMYFACILITY NUMBER:
334845644
ADMINISTRATOR/
DIRECTOR:		KAREN BRAZZILLFACILITY TYPE:
850
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 7DATE:
10/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Denese Keeler/assistantTIME VISIT/
INSPECTION COMPLETED:
10:04 AM
NARRATIVE
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On 10/19/24 at 9:10 am, Licensing Program Analyst's (LPA's) Susan Brewer and Patricia Berry conducted a case management to visit to deliver an amended report from 10/11/24 to the assistant . LPAs were met with the assistant and granted access into the facility. LPA's toured facility and took a census.



Exit interview with assistant, report, appeal rights and notice of site visit issued.


Notice of site visit must be posted for 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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