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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371532
Report Date: 10/10/2024
Date Signed: 10/10/2024 01:14:09 PM

Document Has Been Signed on 10/10/2024 01:14 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 ACADEMYFACILITY NUMBER:
304371532
ADMINISTRATOR/
DIRECTOR:		JOHNSON, SANDRAFACILITY TYPE:
850
ADDRESS:16498 ROYAL OAKTELEPHONE:
(949) 559-6810
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY: 195TOTAL ENROLLED CHILDREN: 62CENSUS: 50DATE:
10/10/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Director, Kathern De La TorreTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Cindy Nguyen conducted an onsite inspection for the purpose of a Case Management - Legal/Non-compliance. LPA and Director, Kathern De La Torre toured the facility inside and outside the floor and yard plan (LIC 999) were verified. Census was taken in individual classrooms. The overall census observed was 8 preschool staff and 50 preschool age children. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 7:00a.m.- 6:00p.m., Monday through Friday. 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.

During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Food is prepared on site; lunch and snacks are provided. Food prep areas were clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. There is drinking water available to children indoors by sports bottles with the child’s name on it. The children's bathrooms are clean and sanitary. Children nap on cots and bedding is stored individually and washed weekly. The facility has conducted an emergency drill within the past six months. The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material of artificial grass produced for the purpose around the climbing equipment, slides and other similar equipment appeared to be enough to absorbs falls.
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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 304371532
VISIT DATE: 10/10/2024
NARRATIVE
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Drinking water in the outdoor activity space is provided by sports bottles with the child’s name on it. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

Staff files were reviewed for staff present during the facility inspection on this date, 8 staff files were reviewed. Health screening and immunizations as required were reviewed. Two out of the eight staff files were missing the Health screening. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a childcare center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Six out of the eight staff mandated reporter training were expired. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 06/02/2025.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of 5 of children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary, Immunization records, Consent for Emergency Medical Treatment, Notification of Parent’s Rights (LIC995A), medical assessment and found to be in compliance. In the areas reviewed the children’s files were found to be in full compliance. Sign in/Sign out procedure was reviewed and meets regulation requirements. This facility utilizes an electronic sign in/out system. Each authorized representative utilizes their own codes as a digital signature.

The director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov licensee may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian. Page 2 of 3
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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: 10/10/2024
NARRATIVE
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Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The licensee was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

This facility provides Incidental Medical Services – IMS. LPA reviewed the storage of medication, equipment, and supplies and reviewed children’s, personnel, and administrative records. A link to PIN 22-02-CCP was provided here: PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child.

Based on LPA observation, record reviews and interview the following violations were observed and are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Section 101216(g)(1) and Health safety code Section 1596.866(b)(1) are being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the Director, Kathern De La Torre. A notice of site visit was given and must remain posted for 30 days. Appeal Rights and deficiencies were discussed. The facility representative was provided 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.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2024 01:14 PM - It Cannot Be Edited


Created By: Cindy Nguyen On 10/10/2024 at 12:37 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: 304371532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
HSC
1596.8662(b)(1)

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(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care ... training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
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Director stated they would arrange for the staff to have the training. A copy of the certificates will be sent to LPA's email address by the due date.
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Based on record review, the licensee did not comply with the section cited above in 6 out of 8 files Mandated Reporter Training Certificates expired, which poses a potential health, safety risk to persons in care.
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Type B
10/31/2024
Section Cited
CCR101216(g)(1)

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(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis... physician not more than one year prior to or seven days after employment or licensure. This requirement is not met as evidenced by:
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Director stated they will send the completed TB test on health screening form to LPA's email by the due.
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Based on record review, the licensee did not comply with the section cited above in 2 out of 8 staffs files were missing the health screening form & TB test, which poses a potential health, safety risk to persons 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:Patricia Magana
LICENSING EVALUATOR NAME:Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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