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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846073
Report Date: 03/13/2025
Date Signed: 03/13/2025 01:28:36 PM

Document Has Been Signed on 03/13/2025 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
364846073
ADMINISTRATOR/
DIRECTOR:
VAN DUZER, MARGARET GALEFACILITY TYPE:
830
ADDRESS:3040 CHINO AVETELEPHONE:
(909) 591-7574
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY: 28TOTAL ENROLLED CHILDREN: 22CENSUS: 15DATE:
03/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:44 AM
MET WITH:Gale Van Duzer, DirectorTIME VISIT/
INSPECTION COMPLETED:
01:38 PM
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A case management visit is being conducted in response to the receipt of an Unusual Incident Report (UIR) from the facility. It was noted on February 19, 2025 an Authorized Representative contacted the facility to find out if their child had an incident while in care. The Authorized Representative informed the facility the child was favoring his/her arm and would be seeking outside medical attention. During the visit with the Doctor they informed the Authorized Representative that the child had a fracture on his/her left wrist. During interviews conducted by the facility the staff attempted to track the child’s day but they did not recall any incidents that would result in an injury such as a fracture. During the interviews with available pertinent parties conducted by the LPA, information disclosed in the written UIR was confirmed to be true and accurate. Based on information gathered, the facility acted appropriately and no violations have been identified during this inspection. The Director notified Licensing according to the Title 22 regulations.

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 Gale Van Duzer, Director.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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