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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 334846083
Report Date: 05/06/2022
Date Signed: 05/06/2022 10:08:15 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2022 and conducted by Evaluator Patricia Berry
PUBLIC
COMPLAINT CONTROL NUMBER: 09-CC-20220422101016
FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
334846083
ADMINISTRATOR:RENFRO, TAMMIEFACILITY TYPE:
830
ADDRESS:14276 SCHLEISMAN RDTELEPHONE:
(951) 272-8700
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:24CENSUS: 12DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Tammie Renfro/DirectorTIME COMPLETED:
10:29 AM
ALLEGATION(S):
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Lack of supervision resulting in a child being injured while in care.
INVESTIGATION FINDINGS:
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On 5/6/2022, at 9:26 am, Licensing Program Analyst (LPA) Patricia Berry conducted a subsequent complaint investigation to deliver final findings. LPA was granted access into the facility. LPA met with Director, toured the facility, and took a census.

It was alleged there was a lack of supervision resulting in a child being injured while in care. During the investigation, LPA interviewed all pertinent parties, including staff, and obtained all pertinent documentation.

Staff stated a child’s fingers were smashed while staff were closing a door to the outside. Staff stated they were aware the child was right by their leg when closing the door; however, failed to take precautionary and preventative measures by moving the child away from the door prior to closing.
(Cont on 9099)
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 09-CC-20220422101016
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 334846083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2022
Section Cited
CCR
101229 (a)(1)
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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1).... Supervision shall include visual observation.
This reguirement was not met as evedienced
by
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Director stated immediately talked with the teachers about safe practices. Director stated she will conduct a training for all staff on this particular incident so all staff will know what safe practices will be put in place going forward.
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Based on interviews conducted and documentation obtained lack of supervision did result in a child being injured while in care.
This is an immediate risk to the health and safety of children in care.
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Director stated she will send the topics and list participants to CCL by 5/9/22.
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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.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 09-CC-20220422101016
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 334846083
VISIT DATE: 05/06/2022
NARRATIVE
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Based on interviews conducted and documentation obtained, lack of supervision did result in a child being injured while in care. The above allegation is substantiated meaning the preponderance of evidence was met.

See 9099D for deficiency. All Type A citations shall be reported 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 with the Director. LPA provided a copy of this report, appeal rights, and a Notice of Site Visit form to the director. LPA observed the Director post the Notice of Site Visit form and a copy of this report. The Notice of Site Visit form and copy of this report must be posted for 30 days. This report must be made available to the public upon request for three years.

SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Patricia Berry
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3