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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 364846072
Report Date: 02/04/2025
Date Signed: 02/04/2025 02:34:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 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
10/11/2024 and conducted by Evaluator Elyse Jones
PUBLIC
COMPLAINT CONTROL NUMBER: 09-CC-20241011161947
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:168CENSUS: 99DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Gale Van Duzer, DirectorTIME COMPLETED:
02:44 PM
ALLEGATION(S):
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Staff served food with known allergens to child in care
INVESTIGATION FINDINGS:
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On February 4, 2025 Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to deliver findings for a complaint. LPA conducted a tour of the facility and took census. During the investigation interviews were conducted with pertinent parties and documentation was collected.

On October 11, 2024 a complaint was received alleging staff served food with known allergens to child in care. During interviews with pertinent parties, it was disclosed on the day of the incident, the facility served a food item from their menu to a child who had a known allergy. Also, during the interviews several staff acknowledged there is an allergy list placed in the kitchen and the classroom, however, the child was still served the food item. During the investigation, the LPA obtained documentation from the child’s file which states the child has an allergy to an ingredient that was being served. LPA also observed an Incidental Medical Plan along with an Epi-Pen for the child. The Director stated, the child is no longer enrolled but after the incident the facility "retrained on the allergy protocol" to ensure another incident does not happen again.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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 5
Control Number 09-CC-20241011161947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 364846072
VISIT DATE: 02/04/2025
NARRATIVE
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Based on all the information obtained from pertinent parties, documentation, records review during inspection, the department has determined the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

See LIC 9099-D for deficiencies.

LPA informed the Director this report dated February 4, 2025 documents one Type A citation which shall be posted for 30 consecutive days as there was an immediate risk to the Health, Safety, or Personal Rights of children in care. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) was provided to facility during this inspection. The LIC 9224/Type A citation must be provided to parents/guardian 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 the verification.


Exit interview was conducted and a copy of this report provided to Gale Van Duzer, Director.
Notice of Site Visit must be posted for 30 day.

A copy of this report must be made available to the public for three years upon request.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 09-CC-20241011161947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 364846072
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2025
Section Cited
CCR
101227(7)(B)
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 Food Services
(7) Modified diets prescribed by a child's physician as a medical necessity shall be provided. (B) A child shall not be served any food to which the child's record indicates he/she has an allergy. This requirement was not met as evidenced by:
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well documented to all staff that Child #1 had a food allergy.

Director agrees to submit a statement of understanding of the regulation and documentation of (trainings, etc.)
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Based on the interviews and record review, the Licensee did not meet Food Services regulation which poses an immediate Health, Safety & Personal Rights risk to the children in care. During the interviews it was disclosed staff were aware of Child #1 having a known food allergy to a food being served and it was
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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: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 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
10/11/2024 and conducted by Evaluator Elyse Jones
PUBLIC
COMPLAINT CONTROL NUMBER: 09-CC-20241011161947

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:168CENSUS: 99DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Gale Van Duzer, DirectorTIME COMPLETED:
02:44 PM
ALLEGATION(S):
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Child in care sustained an injury due to staff’s lack of supervision
INVESTIGATION FINDINGS:
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On February 4, 2025, Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to deliver findings for a complaint. LPA conducted a tour of the facility and took census. During the investigation interviews were conducted with pertinent parties and documentation was collected.

On October 11, 2024 a complaint was received alleging a child in care sustained an injury due to staff’s lack of supervision. It was noted C1 received a 1/4inch laceration on the forehead from a toy that was thrown across the room by another child. During interviews with pertinent parties it was disclosed a child received an injury during Dance & Movement while the staff was simultaneously preparing lunch. Staff confirmed they did not see the incident occur. The Department determined the staff was in ratio at the time of the incident. Although the child did sustain an injury while in care, the staff were positioned to observe the children in care, however, the incident happened quickly.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 09-CC-20241011161947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 364846072
VISIT DATE: 02/04/2025
NARRATIVE
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This agency has investigated the complaint regarding the above allegations. Based on interviews the Department is unable to determine if there was a lack of supervision, therefore, the allegations are UNSUBSTANTIATED. A finding of unsubstantiated means, although the allegations may have happened, or are valid, there is not a preponderance of the evidence to prove the allegations occurred.

Exit interview was conducted and a copy of this report provided to Gale Van Duzer, Director.
Notice of Site Visit must be posted for 30 day.

A copy of this report must be made available to the public for three years upon request.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5