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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370327
Report Date: 09/24/2019
Date Signed: 09/24/2019 02:55:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
304370327
ADMINISTRATOR:LARSON, RUTHFACILITY TYPE:
850
ADDRESS:30722 RICHARD REESE WAYTELEPHONE:
(949) 888-7274
CITY:RANCHO SAN MARGARITASTATE: CAZIP CODE:
92688
CAPACITY:105CENSUS: 65DATE:
09/24/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Staff in chargeTIME COMPLETED:
03:30 PM
NARRATIVE
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An unannounced annual inspection was conducted today by Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek who met with School Education Manager, Derek Weinmann. The assistant director, Kim San Jose was supervising the children in the toddler room who joined LPA during inspection. The director, Ruth Larson was not present on today's inspection. Census was taken. There were a total of 65 preschool children with a total of 7 staff in four different rooms. There were 12 preschool children with one staff in one room, 24 preschool children with 2 staff in another room 17 preschool children with 2 staff in another room and 12 preschool children with one staff in another classroom. A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The facility was reviewed to ensure compliance with license conditions and limitations, staffing and ratios, inaccessibility to poisons, medication, and hazardous items that can pose a danger to children. Equipment and furniture was inspected to ensure it's in good condition, free of sharp, loose or pointed parts. Toilets and sinks were inspected to ensure they are safe and in a sanitary operating condition, floors were inspected for safety and cleanliness. The food preparation area was inspected for cleanliness, free of rodents/vermin, appropriate storage of food, and verification of posted menus. There are no weapons, firearms or bodies of water in the facility. The playground was inspected for safety, good condition of equipment, including appropriate cushioning material around and under high climbing equipment. Staff's files were reviewed for education verification, CPR/First Aid, and new immunization requirements for MMR, Pertussis, and Flu vaccines. (3 staff did not have these requirements on file). A sample of children's files were reviewed for completeness of admission agreement, verification of sign in/out including time the child was signed in/out by authorized representative as well as verification of representatives full legal signature.
The Incidental Medical Services (IMS) was discussed with the staff in charge. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.
Continued on page 2
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 304370327
VISIT DATE: 09/24/2019
NARRATIVE
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The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. The facility has submitted an updated plan for providing Incidental Medical Services (IMS) to our office.
Mandated Reporter Training Certificates are on file for staff except for two staff. This deficiency was cited on next page on LIC 809D.

The Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The licensee was provided a copy of their appeal right (LIC 9058 1/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. The facility representative was informed that they can refer to our Department website at www.ccld.ca.gov for obtaining the quarterly updates.
Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org

A copy of child care provider's guide to safe sleep pamphlet and a copy of Never Ever Shake a Baby pamphlet with the website www.dontshake.org were given to the facility representative on the last inspection.
An updated pamphlet regarding safe sleep regulations in childcare and a pamphlet for lead poisoning facts were given to the staff in charge today.

In the areas that were evaluated, the facility was not compliance of the California Code of Regulations, Title 22, Division 12. Type B citation were issued for lacking 2 staffs' certificates for Mandated Reporter Training and lacking 3 staffs' immunizations on file. Please see next page on LIC 809D.

This report ends here.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: EVERBROOK ACADEMY
FACILITY NUMBER: 304370327
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2019
Section Cited

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two
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years following the date on which he or she completed the initial mandated reporter training. This requirement was not met as evidenced by reviewing 10 staff files today. Staff # 4 and staff # 7 did not have the mandated reporter training certificate on file. This poses a potential health and safety risk to the children in care.
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Type B
10/25/2019
Section Cited

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Employees or volunteers at day care center; immunization requirements; records; exemptions:
Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and Influenza. (Flu shot is optional)
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This requirement was not met as evidenced by reviewing 10 staffs' files today. Staff # 5, 9, and 10 were missing this requirement. The facility failed to meet this section of regulations. This is a potential hazard to the health and safety of children in care.
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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: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3