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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371533
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:21:14 PM

Document Has Been Signed on 11/07/2023 02:21 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:BROWN, BARBARAFACILITY TYPE:
830
ADDRESS:16498 ROYAL OAKTELEPHONE:
(949) 559-6810
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 17DATE:
11/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Director, Barbara BrownTIME COMPLETED:
02:30 PM
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An unannounced case management inspection was conducted on this date by Licensing Program Analyst (LPA), Cindy Nguyen in response to a self-reported incident dated 10/30/23. Present during today’s inspection was the Director, Barbara Brown. Census was taken in individual classrooms. The overall census observed was 9 napping infants, 8 awake infants and 4 infant staff members. A review of adult records 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 10/30/2023 an Unusual Incident Report was filed with the Department to self-report an incident that occurred on 10/30/2023. Director called to inform that they had given Child #1 (C1) the incorrect milk bottle during feeding time.

At 2:15pm when the incident occurred, staff #1 (S1) asked staff (S2) to give child #1 (C1) the bottle. S2 picked up another child, child #2 (C2) and started to feed C2 with C1’s bottle for about 10 seconds. When S1 turned around and told S2 to stop feeding C2. S1 then took the nipple off the bottle and put a clean nipple on the bottle and fed C1. Director stated both parents were notified.

Based on the information gathered from the self-reported unusual incident report, interview with one staff member, statements from the two staff and a physical plant inspection. It was determined that C1 was given the wrong milk bottle during feeding time for about 10 seconds, in which, C1 drank .5 ounces of formula milk. California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101427(g)- Infant Care Food Service is being cited on the attached LIC 809D.

LPA informed Director, Barbara Brown that this report dated 11/07/23, document a Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Continued on Page LIC 809-C

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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: 11/07/2023
NARRATIVE
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Page LIC 809-C

LPA also informed the Director, Barbara Brown to provide a copy of this licensing report dated 11/07/23 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 was conducted with Director, Barbara Brown. Notice of Site Visit was posted during the visit. Director 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 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.

End of Report.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
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Document Has Been Signed on 11/07/2023 02:21 PM - It Cannot Be Edited


Created By: Cindy Nguyen On 11/07/2023 at 01:28 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: 304371533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2023
Section Cited
CCR
101427(g)

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101427(g) Infant Care Food Service (g) A supply of bottles and nipples shall be maintained at the infant care center. Bottles and nipples used by one infant shall not be shared with or used by another infant unless sterilized. This requirement was not met as evidenced by:
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Director stated they had implemented a teacher sign off (2 signatures) before any feeding in the infant room. The Director will provide a written POC and send it to LPA within 24 hours.
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Based on interviewed and self-reported unusual incident report, C1 was given the wrong milk bottle during feeding time for about 10 seconds, in which, C1 drank .5 ounces of formula milk. This poses and immediate health and safety risk to 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.
SUPERVISOR'S NAME:Patricia Magana
LICENSING EVALUATOR NAME:Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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