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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371533
Report Date: 06/06/2023
Date Signed: 06/06/2023 04:35:09 PM

Document Has Been Signed on 06/06/2023 04:35 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:
304371533
ADMINISTRATOR:COURTNEY, JOELLEFACILITY TYPE:
830
ADDRESS:16498 ROYAL OAKTELEPHONE:
(949) 559-6810
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 16DATE:
06/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Barbara Brown Director TIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Patricia Duron conducted an unannounced case management investigation for the incident which the facility self reported to licensing office on 05/18/23. On 5/19/23 LPA Romelia Castanon contacted the Director Barbara Brown for additional information not found on LIC624 which Director had submitted to Community Care Licensing office. The unusual incident report stated an incident occurred at the facility on 5/18/23. The Director stated child 1 (C1) was given food that gave child an allergic reaction, it also stated parent (P1) of C1 was contacted and directed facility to give C1 Benadryl. C1 was picked up by P1 and taken to Doctor.

Upon arrival LPA, was met by Director Barbara Brown and Assistant Director Sandra Johnson, LPA explained the reason for today's visit. Assistant Director Johnson provided a tour of the facility. LPA observed 5 infant staff with 16 infants in care during today’s visit.

A review of facility Personnel Report Summary 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. During today's inspection, LPA Duron interviewed 7 staff, and review files (children and staff) LPA obtained facility roster.

Due to insufficient information available at this time, case management needs further investigations.

An exit interview conducted with Director Barbara Brown . The Director was provided a copy of 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.

Notice of Site Visit was provided and posted. Notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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