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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370327
Report Date: 06/11/2024
Date Signed: 06/11/2024 09:12:17 PM

Document Has Been Signed on 06/11/2024 09:12 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
304370327
ADMINISTRATOR/
DIRECTOR:		LARSON, RUTHFACILITY TYPE:
850
ADDRESS:30722 RICHARD REESE WAYTELEPHONE:
(949) 888-7274
CITY:RANCHO SAN MARGARITASTATE: CAZIP CODE:
92688
CAPACITY: 117TOTAL ENROLLED CHILDREN: 117CENSUS: 32DATE:
06/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Director, Ruth LarsonTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 06/11/24, Licensing Program Analyst (LPA) Cynthia Sun conducted an unannounced visit due to a self-report Unusual Incident Report (UIR) received on 06/04/2024. The UIR stated that on June 3, 2024, during outdoor play Child 1 (C1) was left alone in Two’s classroom for approximately 10-15 minutes. Staff 1 (S1) was the one who noticed that C1 was not in the playground with the rest of the class. (C1) parent was the one who noticed child on school camera playing alone in the Two’s classroom without supervision.

LPA met with Assistant Director. A tour of the facility was conducted, and a census was taken. Observed at the time of the visit was a total 32 children with 5 staff.

A review of the Facility Personnel Report Summary on 6/10/24 indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During the inspection on 6/11/24, LPA interviewed the Director and 1 staff. LPA also inspected the Two’s classroom where C1 was left alone.

During the interview, Director informed LPA incident happened on 06/03/2024 at approximately 4:25 PM during the outdoor play. LPA interviewed S1 who stated on 6/03/24, after changing a diaper, S1 noticed C1 was not in the playground with the class. S1 looked for C1 in the playground and when S1 didn’t find C1 in playground S1 went into the Two’s classroom to check for C1. S1 saw C1, C1’s parent and S2 talking. The director and district manager reviewed the cameras and confirmed C1 was alone for about 10-15 minutes. C1 followed a parent and another child back into the classroom and was then in the classroom alone and unsupervised. C1 was returned safely to the parent by director who had a conversation with the staff involved.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Cynthia Sun
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 304370327
VISIT DATE: 06/11/2024
NARRATIVE
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Director met with S1 on 6/3/24 and reviewed Best Practices Policies and is planning to meet again on 6/11/24 with S1 to retrain on Supervision Policy, Playground Supervision, and Face to Name Head Count. S1 confirmed and understood. Director will also have an all-staff training within the next two weeks on Supervision Policy, Playground Supervision, and Face to Name Head Count. Director will include a Friendly Reminder Bulletin through Sprout About (daily communication App) for parents to use hallway door when leaving Two’s playground. Director also placed signs on doors reminding for door to remain closed. C1 was left alone 10-15 minutes.

Per self-reported incident report and interview with Director, Ruth Larson, it was determined the facility failed to provide visual supervision of a child in care, therefore, California Code of Regulations, Title 22, Division 12, Section 1014229(a)(1)- Responsibility for Providing Care and Supervision is being cited on the attached LIC 809D.

This report cites Type A violation and shall be provided to parents/guardians of children currently enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

Exit interview was conducted with Director, Ruth Larson. Notice of Site Visit was posted during the inspection. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Director was provided a copy of their appeal rights LIC 9058 (03/2022) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.

End of Report

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Cynthia Sun
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2024 09:12 PM - It Cannot Be Edited


Created By: Cynthia Sun On 06/11/2024 at 11:31 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 304370327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2024
Section Cited
CCR
101229(a)(1)

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CCR 101229(a)(1)
101229 Responsibility for Providing Care and Supervision: No child (ren) shall be left without the supervision of a teacher at any time. Supervision shall include visual observation. This requirement is not met as evidence by: Based on self-report UIR and staff interview conducted on 6/111/24, C1 was left alone without any adult supervision. This pose an immediate risk to the health of the children in care.
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Director met with S1 6/3/24 reviewed Best Practices Policies. Director will meet on 6/11/24 to retrain on Supervision Policy, Playground Supervision, and Face to Name Head Count. Director will send a Friendly Reminder Bulletin through Sprout About (App) for parents to use hallway door when leaving Two’s playground.
Director will also have an all-staff training within the next two weeks on Supervision Policy, Playground Supervision, and Face to Name Head Count.
Director will include a Friendly Reminder Bulletin through Sprout About (daily communication App) for parents to use hallway door when leaving Two’s playground.

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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:Judy Hanson
LICENSING EVALUATOR NAME:Cynthia Sun
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
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