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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846072
Report Date: 08/29/2023
Date Signed: 08/29/2023 11:17:09 AM

Document Has Been Signed on 08/29/2023 11:17 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
INLAND EMPIRE CHILD, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
364846072
ADMINISTRATOR:VAN DUZER, MARGARET GALEFACILITY TYPE:
850
ADDRESS:3040 CHINO AVETELEPHONE:
(909) 591-7574
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY: 168TOTAL ENROLLED CHILDREN: 117CENSUS: 86DATE:
08/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Margaret Gale Van DuzerTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Rachel Zeron conducted an unannounced case management visit, LPA met with the director and toured the facility.
Riverside RO received an unusual incident report (UIR) on 08/08/2023 in regards to a child being left unsupervised while sleeping for approximately 5 minutes. A case management visit was conducted in response to the receipt of this unusual incident report (UIR). Facility records reviewed and staff were interviewed. Based on the information gathered, the following violation has been identified: CCR:101229(a)(1) Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
Director notified Community Care Licensing within 24 hours. Director conducted a training on the process name to face, and responsibility to providing care and supervision on 08/08/2023.
See LIC809D for cited deficiency of the California Code of Regulations, Title 22.This is an immediate risk to the health and safety of children care. Civil penalty LIC421IM for $1,000.00 issued today.

An exit interview was conducted with Director Gale Van Duzer and appeal rights discussed, and a copy of this report was provided to the director.
Notice of site visit issued and LPA observed director post notice. LPA Zeron also informed the director to provide a copy of this licensing report dated 08/29/2023 that documents any Type A citation 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 (LIC9224), or other written statement, must be placed in the children's file for verification.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Rachel Zeron
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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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Document Has Been Signed on 08/29/2023 11:17 AM - It Cannot Be Edited


Created By: Rachel Zeron On 08/29/2023 at 10:37 AM
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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 364846072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2023
Section Cited
CCR
101229(a)(1)

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 Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time, Supervision shall include visual observation. This requirement was not met as evidenced by:
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Director conducted training with the staff on 08/08/2023, LPA received a copy of the training as well as an signed acknowledgement from the staff. POC cleared
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A child that was napping was left unattended for approximately 5 minutes.
This is an immediate risk to the health and safety of children care
Civil penalty LIC421IM for $1,000.00 issued today.
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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:Aaron Ross
LICENSING EVALUATOR NAME:Rachel Zeron
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023


LIC809 (FAS) - (06/04)
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