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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020851
Report Date: 02/24/2023
Date Signed: 02/24/2023 04:30:32 PM

Document Has Been Signed on 02/24/2023 04:30 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:
198020851
ADMINISTRATOR:FUENTEZ, TERESAFACILITY TYPE:
830
ADDRESS:520 W. BASELINE RD.TELEPHONE:
(909) 399-0081
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 26TOTAL ENROLLED CHILDREN: 25CENSUS: 18DATE:
02/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Teresa FuentezTIME COMPLETED:
04:30 PM
NARRATIVE
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On February 24,2023 at 9:00 AM, 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 Admin Assistant, Lynette Edwards who guided LPA on a tour of the facility. LPA observed 18 children in care with 5 staff. Director, Teresa Fuentez approximately around 10 am.

Brief Summary of Incident: On 2/16/2023 during indoor playtime approximately 4:15 PM, Child #1 (C1) was discovered unattended in a restroom for approximately 5 minutes by Staff #2 (S2) during a transition time of parent pick-up. S2 had gone into the restroom and had not notice C1 come into the restroom. S2 closed the door and did not observe any children. Upon parent pick-up staff realized C1 was not in the classroom and found C1 in the restroom unharmed.

During this investigation, LPA interviewed, Director, staff #1 (S1), and staff #2 (S2), and obtained a copy of internal incident report and internal investigation. LPA called P1 but was not available to interview. C1 was not able to interview due to the age of the child. LPA took photos of the restroom of the Toddler Classroom where incident occurred.

Director stated that video was reviewed by management and found that S1 and S2 were accurate in their description of the incident. LPA was unable to review video as it only able to be viewed for the first 24 hours only after the incident. S1 during interview did disclose that C1 had been left unattended for 5 minutes. S2 disclosed that they had left C1 in the restroom while putting away a spare jacket. No other staff witnessed the incident. Director stated that staff was interviewed after the incident and S2 was disciplined and policies, procedures, operational documents were reviewed and given to S2.

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.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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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: 198020851
VISIT DATE: 02/24/2023
NARRATIVE
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***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. Licensee/Director was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee/Director.

A notice of site visit was given and must remain posted for 30 days.



An exit interview was conducted, and a copy of this report was provided to Director, Teresa Fuentez along with Notice of Site Visit and Appeal Rights.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/27/2023 10:11 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/24/2023 06:38 PM


Created By: Carolyn Tuba On 02/24/2023 at 03:52 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: EVERBROOK ACADEMY, LLC
FACILITY NUMBER: 198020851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2023
Section Cited
CCR
101429(a)(1)

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Responsibility for Providing Care and Supervision for Infants In addition to Section 101229, the following shall apply: Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.
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Director reviewed company policies and procedures, as well as the child care licensing regulations. Reviewed training materials and reminders of safety and supervision features to staff members.
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To receive safe, healthful ... This requirement was not met as evidence by: an incident that occurred on 2/16/2023 as child was left unattended in bathroom for 5 minutes based on interviews with staff, parent and Director. This poses a potential risk to the health, safety, and personal rights of 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.
SUPERVISOR'S NAME:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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