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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 334845646
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:40:20 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-20230420163433
FACILITY NAME:KINGSTON ACADEMYFACILITY NUMBER:
334845646
ADMINISTRATOR:KAREN BRAZZILLFACILITY TYPE:
830
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY:20CENSUS: 9DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Assistant Sara BrayTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not making sure the kitchen is clean
Staff are not making sure day care children's trays are clean
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 the Assistant, Sara Bray.

It was alleged staff are not ensuring the kitchen is clean due to the refrigerator being dirty. LPA interviewed five staff that reported they have not seen anything excessively dirty and have daily cleaning tasks. On 04/26/23, at 9:13AM LPA toured the facility and took a photo of built-up of dirt and debris on the kitchen’s refrigerator door and door handle.
It was alleged staff are not ensuring the children's individual trays for food storage are clean. LPA interviewed five staff that reported they have not seen the trays dirty and that trays are cleaned on a regular basis.
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-20230420163433
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: 334845646
VISIT DATE: 05/19/2023
NARRATIVE
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On 04/26/23, at approximately 9:14AM LPA toured the facility and took five photos of the children’s baskets for food located in the refrigerator and cabinet. LPA observed some of the baskets had debris/dust on the bottom in addition to debris on outer cabinet door where trays are stored.
Based on LPA’s observation and photos obtained, the preponderance of evidence standard has been met, therefore the above allegations are 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 UPON REQUEST 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: 4 of 5
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-20230420163433

FACILITY NAME:KINGSTON ACADEMYFACILITY NUMBER:
334845646
ADMINISTRATOR:KAREN BRAZZILLFACILITY TYPE:
830
ADDRESS:6048 ETIWANDA AVENUETELEPHONE:
(951) 681-4182
CITY:MIRA LOMASTATE: CAZIP CODE:
91752
CAPACITY:20CENSUS: 9DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sara BrayTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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2
3
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5
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8
9
Staff are not meeting day care child's needs
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 theAssistant Sara Bray.

It was alleged staff are not meeting day care child's needs by not cleaning the children.

On 04/26/23, LPA toured the facility throughout the day between 8:30AM and 4:30PM. LPA observed teachers attentive to feeding, toileting, diapering, hand washing, and cleaning/wiping after feeding or for runny noses.
LPA interviewed five staff. All interviews’ reported children are cleaned up with wipes and/or handwashing in addition to using bibs. Interviews also noted calls are made for parent pick up for runny noses with green mucus.
Unsubstantiated
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: 2 of 5
Control Number 09-CC-20230420163433
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: 334845646
VISIT DATE: 05/19/2023
NARRATIVE
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Photos obtained during this investigation revealed crumbs on a child’s face and a child with a runny nose
however, LPA could not identify time frames nor definitively determine if children were not cleaned up in a timely manner.

LPA obtained conflicting information from what was alleged. The evidence collected was not sufficient to substantiate or refute the above allegation. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
An exit interview was conducted, a copy of this report and Notice of Site Visit was provided to the Assistant. LPA observed the Notice of Site Visit was posted by staff. THIS REPORT MUST BE AVAILABLE TO THE PUBLIC FOR THREE YEARS UPON REQUEST.
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: 3 of 5
Control Number 09-CC-20230420163433
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: 334845646
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 Buildings and Ground (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 evidence by:
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Facility will submit pictures of washed trays and refrigerator to the department 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 infant trays for storing food and outside of infant refrigerator had built up dirt and debris. 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: 5 of 5