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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371533
Report Date: 01/21/2025
Date Signed: 01/21/2025 12:48:00 PM

Document Has Been Signed on 01/21/2025 12:48 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
304371533
ADMINISTRATOR/
DIRECTOR:		DE LA TORRE, KATHERNFACILITY TYPE:
830
ADDRESS:16498 ROYAL OAKTELEPHONE:
(949) 559-6810
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 13DATE:
01/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Director DE LA TORRE, KATHERNTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 1/21/2025 at 9:00AM, Licensing Program Analyst (LPA), Christine Jung, conducted an unannounced case management-deficiency inspection to follow up on an incident that was self-reported to the Department. Upon arrival, LPA met with Director, Kathern De La Torre. LPA disclosed the purpose of the inspection and was led on a tour of the facility. There were 13 children and 4 staff members present.

The facility submitted an unusual incident report (UIR) to the Department on 1/15/2025 reporting an incident surrounding Child 1 (C1). The facility reported that on 1/14/2025, C1 was fed another child’s bottle.

Interviews were conducted with three (3) staff members. Based on interviews, staff confirmed that Staff 1 (S1) and Staff 2 (S2) fed C1 the wrong bottle. S1 picked up Child 2’s (C2) bottle and fed C1 without the checking the name label on the bottle. When S2 came into the room, S1 handed C1 to S2, as well as the bottle that C1 was drinking. S2 continued feeding C1 the same bottle. When S1 picked up a second bottle to feed C2, S1 looked at the bottle label and realized that the bottles for C1 and C2 had been mixed up.

The Facility staff reported the incident to the Department in a timely manner. Based on the information obtained and interviews conducted, one Type B citation for Infant Care Food Service is being cited on LIC809D.

Exit interview conducted with Director Kathern De La Torre.

Notice of Site Visit (LIC9213) was provided and shall be posted for 30 days.

End of report.
SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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Document Has Been Signed on 01/21/2025 12:48 PM - It Cannot Be Edited


Created By: Soo Jin Jung On 01/21/2025 at 12:21 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: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
101427(g)

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101427(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... This requirements was not met as evidenced by:
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Director stated that they are putting in place a two-step accountability procedure for feeding. Director stated they will provide staff training documents with signatures and email them to LPA by due date.
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Based on interviews, the licensee did not comply with the section cited above in that, staff fed Child 1 (C1) from a bottle that belonged to Child 2 (C2), which poses a potential health, safety or personal rights risk to persons 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:Nguyen K Tran
LICENSING EVALUATOR NAME:Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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