<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334845645
Report Date: 11/28/2022
Date Signed: 11/28/2022 04:08:31 PM

Document Has Been Signed on 11/28/2022 04:08 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:
334845645
ADMINISTRATOR:KAREN BRAZZILLFACILITY TYPE:
840
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY: 49TOTAL ENROLLED CHILDREN: 49CENSUS: 20DATE:
11/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Karen BrazzillTIME COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On the date and time listed above, a case management visit was conducted by Licensing Program Analyst (LPA) Giselle Carbullido to deliver amended reports. During today’s visit, LPA toured the facility and census was taken, with 20 children present. LPA met with Karen Brazzil, Director to deliver amended report.

Exit interview conducted and a copy of this report and notice of site visit was provided to the Director. A copy of this report must be made available to the public for 3 years.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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 1