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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020849
Report Date: 08/27/2025
Date Signed: 08/27/2025 02:56:31 PM

Document Has Been Signed on 08/27/2025 02:56 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:EVERBROOK ACADEMY, LLCFACILITY NUMBER:
198020849
ADMINISTRATOR/
DIRECTOR:		FUENTEZ, TERESAFACILITY TYPE:
850
ADDRESS:520 W. BASELINE RD.TELEPHONE:
(909) 399-0081
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 132TOTAL ENROLLED CHILDREN: 82CENSUS: 66DATE:
08/27/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Director, Teresa FuentezTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On August 27, 2025, Licensing Program Analysts (LPA) Diana Ortiz and Joanne Solorio-Campos, conducted an unannounced Case Management-Incident Report visit. LPAs met with Director Teresa Fuentez who guided LPA on a tour of the facility. LPA observed 66 children and 19 staff present during this visit. The department received an unusual incident report on 7/18/25 via email for an incident that occurred on 7/02/25. Per Title 22 Regulations CCR 101212(d)(1)(B) the facility failed to report the incident in a timely manner.

During today’s visit, LPAs conducted interviews with the Director and Staff. LPAs observed the classroom where the incident occurred. LPAs observed the playhouse fridge was removed from the classroom and moved to a room which is not being utilized (Pre K room).

LPAs toured the facility and entered the classroom where the incident occurred. Director explained the incident occurred at around 10am during clean up time as they were getting ready to go outside. During the time of the incident, there were 16 children and two staff present. S#1 was helping other children clean up when the incident occurred. S#1 stated C#1 was helping clean up the “home living area” of the room and when she turned around they heard C#1 cry. When S#1 walked over to C#1, S#1 stated that there was a lot of blood on the floor. When S#1 observed C#1 her thumb was bleeding and part of the tip of her thumb along with a piece of her nail was on the floor. Staff immediately responded, and administered first aid. S#1 asked S#2 to assist and S#2 then grabbed C#1 finger tip from floor and placed it on a napkin and placed the napkin inside the cup. S#1 then stated C#1 was brought to the front of the office where she then waited for Assistant Director to contact her parents. S#1 stated C#1 waited approximately 40 minutes before the Nanny and Mother showed up and then took her to urgent care.

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NAME OF LICENSING PROGRAM MANAGER: Katrina Chicote
NAME OF LICENSING PROGRAM ANALYST: Diana Ortiz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: EVERBROOK ACADEMY, LLC
FACILITY NUMBER: 198020849
VISIT DATE: 08/27/2025
NARRATIVE
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C#1 received a few stiches on the finger. The child returned to the facility on Monday, July 7, 2025 with medical clearance stating not to get her thumb wet as it was on a bandage. Parents were provided with an incident report from the facility and LPA obtained a copy.

After interviews, observation of the areas and documentation of the injury, it was determined that staff were unable to prevent the injury from happening; therefore, there is no preponderance of evidence to determine that a regulatory violation occurred, the incident was determined to be an accident.

However, Per Title 22 Regulations CCR 101212(d)(1)(B) the facility failed to report the incident in a timely manner. This poses a potential risk to the health, safety and personal rights of children in care. LPAs reviewed title 22 regulations with director about Reporting Requirements and the many ways of submitting an Unusual Incident Report. Director understood.

Based on this information, the following deficiencies on the attached LIC 809D 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.

Exit interview conducted and report reviewed with Director Teresa Fuentez.

A notice of site visit was provided, and appeal rights were provided and discussed.

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NAME OF LICENSING PROGRAM MANAGER: Katrina Chicote
NAME OF LICENSING PROGRAM ANALYST: Diana Ortiz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2025 02:56 PM - It Cannot Be Edited


Created By: Diana Ortiz On 08/27/2025 at 01:47 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: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2025
Section Cited
CCR
101212(d)(1)(B)

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Facility shall report to the Department by telephone or fax within the Departments next working day and during its normal business hours...Any injury to a child that requires medical treatment

This requirement is not met as
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Per Director, she explained reporting requirements to Assistant Director and staff.All are aware that Department will be notified. All staff attended school emergency response procedure training and have signed aknowlegment.
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evidence by...based upon interviews and documentation recieved, the facility did not report the incident within 24hours after the incident occured. This poses a potential risk to health, safety and/or personal rights to the 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.
Katrina Chicote
NAME OF LICENSING PROGRAM MANAGER:
Diana Ortiz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2025


LIC809 (FAS) - (06/04)
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