304371532-9-19-2023-06-CC-PDUN-CVTRH8-20230919130156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371532
Report Date: 09/19/2023
Date Signed: 09/19/2023 01:03:22 PM

Document Has Been Signed on 09/19/2023 01:03 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	EVERBROOK ACADEMY		FACILITY NUMBER:	304371532
ADMINISTRATOR:	BROWN, BARBARA		FACILITY TYPE:	850
ADDRESS:	16498 ROYAL OAK		TELEPHONE:	(949) 559-6810
CITY:	IRVINE	STATE: CA	ZIP CODE:	92618
CAPACITY: 195	TOTAL ENROLLED CHILDREN: 195	CENSUS: 62	DATE:	09/19/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Barbara Brown, Director		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA ) Patricia Duron conducted an on-site inspection for the purpose of a Case Management Incident Inspection on 9/19/2023. LPA Duron met with Director Barbara Brown. There was a total of 62 preschool children present with 8 preschool staff at the time of visit.

A review of staff criminal clearance records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Today's Case Management inspection is being conducted in response to a self-reported incident, reported to the Orange County Community Care Licensing Regional Office on 5/19/23. The Director stated child 1 (C1) was sleeping on cot and S2 placed their foot under C1’s cot and lifted the cot and wiggled it a dozen times.

At the time of the incident C1 was sleeping on their cot, S1 was preparing snack. S2 stated they placed their foot under C1’s cot a little. S1 stated S2 moved C1’s bed with their foot and lifted up C1’s bed up and down slightly.

During the inspection, LPA interviewed the Director and 2 staff members. 2 out of 2 staff members stated S2 placed their foot under C1’s cot and moved cot with their foot attempting to wake up C1 for snack.

Director Barbara Brown stated S2 involved in incident was given an action plan, S2 was trained on personal rights, and reminded to let sleeping child wake up on their own. LPA reviewed documentation provided from Director for S2 on day of visit.

Based on LPA's observations, and interviews conducted, the preponderance of evidence standard has been met. Facility attempted to wake up sleeping child which poses an immediate risk to Health and Safety. California Code of Regulations, Title 12, Division 22 Section 101223 Personal Rights (a)(3).

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: EVERBROOK ACADEMY	FACILITY NUMBER: 304371532
	VISIT DATE: 09/19/2023

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LPA Duron informed Director Barbara Brown that this report dated 9/19/2023 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Duron informed the Director Barbara Brown to provide a copy of this licensing report dated 9/19/2023 that documents any Type A citation(s) 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.

Exit interview conducted and report was reviewed with the Director Barbara Brown. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights were explained. The Director was provided with a copy of appeal rights (LIC 9058 01/16) 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. First level appeals should be sent to the regional manager to the address listed above.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2023 01:03 PM - It Cannot Be Edited

Created By: Patricia Duron On 09/19/2023 at 11:39 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: 304371532
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/19/2023 Section Cited CCR 101223(a)(3)	1 2 3 4 5 6 7	101223 Personal Rights (a)(3) (a) The licensee shall ensure that each child is accorded the following personal rights:(3)To be free from corporal..... interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter,clothing, medication or aids to physical functioning.	1 2 3 4 5 6 7	Director provided LPA with a written statement stating facility's plan on providing training to staff on Personal Rights. Director will provide documentation with staff members name/signatures stating they were present for training. POC will be submitted to LPA by 9/29/23.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: Based on LPA’s interviews and S2 admitting to placing their foot under C1’s cot a little. S1 stated S2 moved C1’s bed with their foot and lifted up C1’s bed up and down slightly. This poses an immediate risk to Health and Safety to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Thuy Ho

LICENSING EVALUATOR NAME:

Patricia Duron

LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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