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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020849
Report Date: 08/09/2023
Date Signed: 08/09/2023 04:33:58 PM

Document Has Been Signed on 08/09/2023 04:33 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:EVERBROOK ACADEMY, LLCFACILITY NUMBER:
198020849
ADMINISTRATOR:FUENTEZ, TERESAFACILITY TYPE:
850
ADDRESS:520 W. BASELINE RD.TELEPHONE:
(909) 399-0081
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 132TOTAL ENROLLED CHILDREN: 102CENSUS: 101DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Teresa FuentezTIME COMPLETED:
04:40 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 8/9/2023 at 2:15 PM, Licensing Program Analyst (LPA) Carolyn Tuba conducted an unannounced case management inspection at the above facility. A COVID-19 risk assessment was conducted prior to entering the facility. LPA met with Director Teresa Fuentez who guided LPA on a tour of the facility. LPA observed 101 children in care with 11 staff.

Brief Summary of Incident: On 7/25/2023 during a transition around 10 AM, Child #1 (C1) was discovered unattended in a classroom for approximately 10 minutes by Staff #2 (S2). During a transition with Staff #1 (S1) and S2, they had taken children to attend a show in the Brooks classroom and when S2 had returned to the Early Preschool classroom during a break to get their water bottle, C1 was discovered. There are cameras in the classroom and C1 was observed by a relative who had seen C1 washing hands after using the restroom with no staff in attendance. S1 disclosed that when leaving the classroom to take children the Name to Face roster was available. Both S1 and S2 did not follow facility’s procedures, which is to count and confirm that are children are all present. C1 was unharmed and returned with her peers and teachers in care. LPA conducted an interview with Parent #1 (P1) and confirmed that C1 was alone in the classroom with no adults present. During a visit conducted on 8/4/2023, LPA interviewed Director who confirmed the incident and had self reported on 7/25/2023 via telephone call to the Department and a Unusual Incident Report was mailed to the Community Care Licensing Department and received on 8/2/2023. The facility reported the incident in a timely manner. Director stated that video was reviewed by management and confirmed that the incident occurred. LPA was unable to review video as it can only be viewed for the first 24 hours after the incident. Director stated that S1 and S2 were spoken to and both S1 and S2 were disciplined. Director also stated that a training will be conducted on 8/16/2023 and procedures of counting children and using name to face will be reviewed with all staff.

The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.
page 1 of 2
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: EVERBROOK ACADEMY, LLC
FACILITY NUMBER: 198020849
VISIT DATE: 08/09/2023
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
26
27
28
29
30
31
32
***For TYPE A ----A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent.Director will be printing form from the Department's website.

The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative.


An exit interview was conducted, and a copy of this report, along with appeal rights was provided to Director, Teresa Fuentez.

page 2 of 2
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 08/09/2023 04:33 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 08/09/2023 at 04:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: EVERBROOK ACADEMY, LLC
FACILITY NUMBER: 198020849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections....
Supervision shall include visual observation.
1
2
3
4
5
6
7
Director stated that a training will be conducted on 8/16/2023 and procedures will be reviewed with all staff of name to face children's roster and counting of children during transtions. Director will be sending LPA via email itinerary, handouts and signatures of those in attendance.
8
9
10
11
12
13
14
To receive safe, healthful ... This requirement was not met as evidence by: an incident that occurred on 7/25/2023 as child was left unattended in classroom for 10 minutes based on interviews with staff, parent and Director. This poses an immediatel risk to the health, safety, and personal rights of children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3