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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846084
Report Date: 09/12/2023
Date Signed: 09/12/2023 11:42:17 AM

Document Has Been Signed on 09/12/2023 11:42 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:
334846084
ADMINISTRATOR:RENFRO, TAMMIEFACILITY TYPE:
840
ADDRESS:14276 SCHLEISMAN RDTELEPHONE:
(951) 272-8700
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 2DATE:
09/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Tammie Renfro, DirectorTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct a Case Management inspection in response to the receipt of an unusual incident report (UIR) from the facility dated August 23, 2023. It documents an incident involving a child who fell and hit his/her head on a small book case bench. The child was playing "monkey in the middle" with friends and tripped over his/her feet in the classroom. There was one teacher present with eleven children. Appropriate supervision and care was being provided. The facility notified the Authorized Representative immediately after the incident occurred, provided an Incident Report to the parent and reported to Licensing.

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

The child was taken to seek outside medical care for a follow up. The child stayed home 24 hours for rest/observation. Child returned to the facility on August 24, 2023.

Based on the information gathered, the incident was an accident as facility staff followed care and supervision protocols. The child continues to attend the facility. The 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: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 334846084
VISIT DATE: 09/12/2023
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A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Tammie Renfro, Director.

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

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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