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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198020849
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:28:26 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2024 and conducted by Evaluator Carolyn Tuba
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20240216111259
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:132CENSUS: 78DATE:
04/03/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teresa FuentezTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff are operating out of ratio.
INVESTIGATION FINDINGS:
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On 4/3/2024, Licensing Program Analyst (LPA) Carolyn Tuba conducted an unannounced complaint inspection to deliver findings of the above allegation. A Covid risk assessment was conducted. LPA met with Director, Teresa Fuentez and a census was taken of 78 children present with 11 staff.
LPA conducted interviews, and reviewed records on 2/22/2024, 3/1/2024 and 3/26/2024. LPA, Tuba conducted interviews with Reporting Party (RP), Director (D), Staff #1 (S1), #2 (S2), #3 (S3), #4 (S4), #5 (S5), Parent #1 (P1), P#3 (P3). Parent #2 (P2) LPA was not able to reach for interview.
Reporting Party alleged staff are operating out of ratio. During the course of the investigation, LPA conducted interviews with Staff #1 (S1), #2 (S2), #3 (S3) and #5 (S5) who stated that anywhere from 5 to 20 minutes staff has been out of ratio at least 3 times a week. According to staff (S1), (S2) & (S3) interviewed they seem to go over at least two (2) to three (3) children than the ratio allows of 1 staff:12 childr.ears to occur in the morning time approximately between the hours of 7:45 am - 8:30 am. LPA and Director discussed that there seems to be a lack of communication with morning staff letting the front office know beforehand, that they will be out of ratio.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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 6
Control Number 33-CC-20240216111259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/03/2024
NARRATIVE
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According to Staff they are aware that they should call the front office or send additional children to other classrooms but have had several occasions where they have been going over ratio. During an interview with the Director, she confirmed that the staff is directed to call the front office when staff are out of ratio, so they can send someone from the front office to assist. Director also stated that Classroom Daily Ratio Attendance Tracking is conducted throughout the day. LPA obtained copies from the dates of 2/13/2024, 3/25/2024 and 3/26/2024. LPA reviewed the Daily Ratio Attendance Tracker, and it does not reflect classrooms being within ratio, but interviews confirmed otherwise. Parents (P1) and (P3) were interviewed but they did not make any disclosures.

Based on LPA’s interviews, the preponderance of the evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, 101216.3, the deficiencies are being cited on the attached LIC 9099D.

Notice of site visit was given to the licensee and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director, Teresa Fuentez.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 33-CC-20240216111259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
101216.3(a)
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Teacher-Child Ratio ( a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.
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Per Director they will be holding a staff meeting and discussing ratios and will provide LPA an itinerary of the meeting discussion and signatures of staff in attendance.
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This requirement was not met as evidence by: Based on interviews conducted staff to children ratio has gone over in the mornings for 5 to 20 minutes at least 2 to 3 children and at least 3 times a week,This poses 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: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
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