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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371532
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:37:34 PM

Document Has Been Signed on 10/16/2024 02:37 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: 195CENSUS: 45DATE:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Kathern De La Torre Director TIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Patricia Duron conducted an unannounced visit due to a self-report Unusual Incident Report (UIR) received on 8/9/24. The UIR stated on 8/8/24 C1 was left unsupervised on the playground. LPA met with Director. A tour of the facility was conducted, and a census was taken. Observed at the time of the visit was a total 45 preschool children with 8 staff. A review of the Facility Personnel Report Summary indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
On initial visit, 8/15/24, LPA interviewed the Director and 2 staff. LPA also inspected the playground where C1 was left unsupervised. LPA was unable to interview C1 due to child being non-verbal.
During the interview, the Director stated on 8/8/24, Child 1 (C1) was outside by themselves when Staff 3 (S3) came outside and observed C1 running towards S3. S3 informed the Director and the Director brought C1 back to their room. The Director stated C1 was in the playground for 2 minutes when S3 saw C1. Director stated, S1 and S2 were checking Face to Name form and realized C1 was missing when the Director brought C1 back to the staff.
Director immediately met with S1 and S2 and verbally discussed the importance of face to name, especially when transitioning from one location to another. Director stated, an all staff training will be conducted on Saturday 8/17/24, which management will discuss the importance of supervision, transitions, face to name, head count, and communication.
Based on self-reported incident, and information gathered from LPA’s interviews, it was determined the facility failed to provide visual supervision of a child in care, therefore, California Code of Regulations, Title 22, Division 12, Chapter 1 Section 101229(a)(1) Care and Supervision has already been cited on 10/16/24 regarding the same incident.
Exit interview was conducted. 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 and their signature on this form acknowledges receipt of these rights. 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
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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