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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846082
Report Date: 08/25/2022
Date Signed: 08/25/2022 11:16:31 AM

Document Has Been Signed on 08/25/2022 11:16 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
334846082
ADMINISTRATOR:RENFRO, TAMMIEFACILITY TYPE:
850
ADDRESS:14276 SCHLEISMAN RDTELEPHONE:
(951) 272-8700
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 168TOTAL ENROLLED CHILDREN: 168CENSUS: 73DATE:
08/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Tammie Renfro, DirectorTIME COMPLETED:
11:25 AM
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Licensing Program Analysts (LPAs) Elyse Jones and Blanca Ruiz arrived at the facility to conduct a case management inspection in response to the receipt of an unusual incident report (UIR) from the facility. It documents an incident involving Child #1 who fell and hit his/her head while playing outside in the sprinkler during water play. Two teachers were present with eight children. Appropriate supervision and care was being provided. The facility notified the Authorized Representative immediately after the incident occurred.

At the time of the inspection, LPAs toured the facility, took census, and met with Director, Tammie Renfro. Additional interviews with pertinent parties were conducted to obtain details regarding the reported incident and records were reviewed. During the facility tour the area in which the incident occurred was observed.

Child #1 was taken to the doctor for a follow up, and parents decided to keep child home for observation. Child #1 return to the facility on July 26, 2022.

Based on the information gathered, the incident was an accident as facility staff followed care and supervision protocols. First Aid was provided, Authorized Representative was immediately notified of the incident and Licensing was notified. Child #1 continues to attend the facility. Facility acted appropriately and was found to be in substantial compliance during this inspection.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 334846082
VISIT DATE: 08/25/2022
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An exit interview was conducted, a copy of this report and a Notice of Site Visit was provided to facility Director, Tammie Renfro.

A copy of this report must be made available to the public, at the facility site, for 3 years. Notice of Site Visit must be posted for 30 days.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC809 (FAS) - (06/04)
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