304371533-9-19-2023-06-CC-PDUN-CVTPG5-20230919111747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371533
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:19:06 AM

Document Has Been Signed on 09/19/2023 11:19 AM - 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:	304371533
ADMINISTRATOR:	BROWN, BARBARA		FACILITY TYPE:	830
ADDRESS:	16498 ROYAL OAK		TELEPHONE:	(949) 559-6810
CITY:	IRVINE	STATE: CA	ZIP CODE:	92618
CAPACITY: 30	TOTAL ENROLLED CHILDREN: 30	CENSUS: 16	DATE:	09/19/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Barbara Brown, Director		TIME COMPLETED:	11:30 AM

NARRATIVE

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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 16 infant age children present with 4 infant 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 5/18/23. 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.

At the time of the incident 12:30 p.m. C1 began vomiting and was observed to have a skin rash on the chest area. C1 was picked up by parent at 1:01 p.m. and taken to emergency care. On the UIR it was stated to LPA Castanon that the facility was aware C1 had an egg allergy and allergy lists are posted.

During the inspection, LPA interviewed Director, Assistant Director and staff that were directly involved in the incident, as well as inspecting the kitchen and classrooms where the allergy lists are posted.

Director Barbara Brown stated facility took action regarding the incident, and staff member involved in the incident was terminated.

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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: 304371533
	VISIT DATE: 09/19/2023

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Based on LPA observations, child file review, and interviews conducted, the preponderance of evidence standard has been met. Facility failed to meet the needs of the child in care and served an item listed as an allergic item on LIC 702 Child's Preadmission Health History-Parents/Authorized Representative Report, LIC627 Consent for Emergency Medical Treatment, and Enrollment Application Information form which poses an immediate risk to Health and Safety. California Code of Regulations, Title 12, Division 22 Section 101227(7)(B) is being cited for Food Services.

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 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 11:19 AM - It Cannot Be Edited

Created By: Patricia Duron On 09/19/2023 at 10:29 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: 304371533
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 101227(7)(B)	1 2 3 4 5 6 7	101227 Food Service (7) Modified diets prescribed by a child's physician as a medical necessity shall be provided.(B) A child shall not be served any food to which the child's record indicates he/she has an allergy.The above requirement is not met by:	1 2 3 4 5 6 7	Facility Director provided LPA with a written statement on how the facility will prevent this incident to occur again. On 9/19/23 Director provided LPA with documentation stating staff training on infant feeding prodedure on 5/19/23. POC was cleared on 9/19/23
	8 9 10 11 12 13 14	evidence of facility serving an allergic item (egg) to Child #1 during lunch time and the Item was listed on LIC 702 Child's Preadmission Health History-Parents/Authorized Representative Report, LIC627 Consent for Emergency Medical Treatment, and Enrollment Application Information form which was received upon admission by the facility. 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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