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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370327
Report Date: 10/15/2025
Date Signed: 10/15/2025 03:46:31 PM

Document Has Been Signed on 10/15/2025 03:46 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 CO CHILD CARE, 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: 59DATE:
10/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Assistant directorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek conducted an onsite case management inspection for the purpose of checking into an incident that the facility self reported to our office on 10/7/2025. LPA met with assistant director, Shipra Shrivastava. LPA took census. There were a total of 59 preschool children with 6 staff in three different classrooms. According to the self report incident, on 10/7/2025 around 10:30 am, a 3 year old child (C1) was left unattended on the playground during transitioning from playground to classroom for 2 minutes.



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

Today, LPA interviewed the staff who were involved in the above incident. (S1, S2, S3, S4, and S5). C1 was too young to be qualified for interview. During the interview with staff members, S1 stated S1 did not notice C1 was missing from the group. S1 was with S2 with 14 preschool children during transitioning from playground to the school's hallway and then children's classroom. S2 stated S2 conducted face to name head counts while standing at the door leading to the school hallway. S2 confirmed S2 observed C1 went inside joining other children in the hallway. However, S2 thinks C1 must have gone back outside on the playground without S2 noticing. S3 stated S3 was with her own group of children in adjacent playground separated by fence where C1 was left unattended. S3 did not realize C1 was left on the playground while C1's group were all inside. Continued on page 2
NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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 4
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 304370327
VISIT DATE: 10/15/2025
NARRATIVE
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According to S3, later on after C1's group went inside, S3 and other children noticed C1 standing at the other side of the fence on the playground. S3 could not confirm the estimated time C1 was left unattended on the playground. S1 and S2 could not confirm the length of the time C1 was left unattended. S3 notified S4, and S5 of the incident. S5 stated S5 took C1 back to the classroom. That was the time S1 and S2 noticed C1 was not in their group when transitioned from the playground to the hallway and classroom. LPA estimated C1 was left unattended on the playground for couple of minutes .

Per facility self reported incident and interview with involved staff in the incident, 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 101229(a)(1)- Responsibility for Providing Care and Supervision is being cited on the attached LIC 809D next page.

The assistant director, Shipra Shrivastava was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00. LPA Malek informed the assistant director, Shipra Shrivastava that this report dated 10/7/2025 documents type A citation shall be posted for 30 consecutive days as there is immediate risks to the health, safety, or personal rights of children in care. Also, LPA Malek informed the assistant director, Shipra Shrivastava to provide a copy of this licensing report dated 10/7/2025 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. The assistant director, Shipra Shrivastava provided with a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

The exit interview was conducted with assistant director, Shipra Shrivastava.



End of report

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/15/2025 03:46 PM - It Cannot Be Edited


Created By: Mahnaz Malek On 10/15/2025 at 02:32 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 304370327

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2025
Section Cited
CCR
101229(a)(1)

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101229(a)(1) 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: self reported incident, and
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Assistant director agreed to meet with staff and review best practices policies regarding conducting accurate name to face head count and supervising children at all times.
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interviewing involved staff in the incident of 10/7/2025 that a 3 year old child was left unattended on the playground during transitioning to the classroom for couple of minutes. This poses an immediate risk to the health and safety of children in care.
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The agenda and staffs' signatures acknowledging supervising children at all times will be sent to LPA's email address by the due date of 10/16/2025.

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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.
Thuy Ho
NAME OF LICENSING PROGRAM MANAGER:
Mahnaz Malek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


LIC809 (FAS) - (06/04)
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