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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304371532
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:48:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2024 and conducted by Evaluator Patricia Duron
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20240812135232
FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
304371532
ADMINISTRATOR:JOHNSON, SANDRAFACILITY TYPE:
850
ADDRESS:16498 ROYAL OAKTELEPHONE:
(949) 559-6810
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY:195CENSUS: 45DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kathern De La Torre Director TIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Facility staff left day care child outside unattended
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Duron conducted an unannounced complaint visit to deliver the complaint findings. This is a continuation of the investigation initiated on 8/15/24, LPA met with Director, Kathern De La Torre and informed the director of the purpose of the visit. Census was taken. The overall census observed was 8 preschool staff and 45 preschool children.
A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
On 8/12/24 a complaint was filed with the Licensing office by Reporting Party (RP) stating Facility staff left day care child outside unattended. RP stated on Friday, 8/9/24, a child was left outside on the playground unattended in the afternoon.
During the course of investigation, LPA interviewed 3 staff members, 5 children and 4 parents, and reviewed records.
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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 06-CC-20240812135232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/16/2024
NARRATIVE
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This incident was self-reported to Community Care Licensing (CCL) office on 08/09/2024. The facility reported on 08/08/2024, C1 was left unsupervised on the playground.

LPA interviewed 3 staff members. 3 out of 3 staff members stated they witnessed C1 left outside unattended.

Staff 2 (S2) stated, on Friday 8/9/24 S1 and S2 each had their own face to name list for both classrooms outside. When the group was ready to come into the classroom, S2 checked their name to face list. S2 came in first and then S1 sent their kids with S2’s group. S1 was checking their name to face list and S1 noticed someone was missing. As soon as S1 noticed that S4 came and brought C1 in. S2 stated, C1 was left outside for about 2 minutes



Staff 3 (S3) stated, “I saw C1 around 4:05pm, my class were going outside to the playground around 4:05, and I saw C1 running towards me, and I hold C1’s hand. I called S4 at 4:07, to let them know about C1. S4 came out right away and took C1 back to their class”.

S4 stated, S3 came out with their group of kids, and saw C1 walking around in the playground. C1 was probably out there for 2 minutes. S1 and S2 were doing face to name and realized C1 was missing. S4 brought C1 back to S1 and S2.

LPA interviewed 5 children. All interviewed children did not make any disclosures regarding the above allegations.

LPA Duron interviewed 4 parents. All interviewed parents stated they did not have any concerns with facility.

Based on LPA’s interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1 Section 101229 Responsibility for Providing Care and Supervision is being cited on attached LIC 9099D.



Page 2 of 3.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 06-CC-20240812135232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/16/2024
NARRATIVE
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This requirement is met as evidence by: Based on LPA’s interviews, 3 out of 3 staff stating they witnessed C1 left on playground unsupervised for about 2 minutes which poses a potential health risk to the children in care.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were provided. The facility representative was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. Any proposed changes to the physical plant, including telephone number, shall be immediately reported to the Department.



The 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 $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door.

Page 3 of 3. End of Report.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 06-CC-20240812135232
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2024
Section Cited
CCR
101229(a)(1)
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101229 Responsibility for Providing Care and Supervision (a)(1) No child(ren) shall be left without the supervision of a teacher at any time .... 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Director provided LPA with a written statement, stating the training she has provided to staff, including an updated transition procedure which staff informs the Director/front desk of their census when they are transitioning indoors/outdoors.
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This requirement is met as evidence by: Based on LPA’s interviews, 3 out of 3 staff stating they witnessed C1 left on playground unsupervised for about 2 minutes which poses a potential health risk to the 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.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
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