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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370327
Report Date: 03/02/2020
Date Signed: 03/02/2020 11:42:02 AM

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:117CENSUS: 66DATE:
03/02/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:DirectorTIME COMPLETED:
12:00 PM
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A Case Management investigation was conducted today for the purpose of checking into an unusual incident which was self reported to our office by the facility representative on 2/24/2020.
Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek met with director, Ruth Larson at arrival time. According to census, there were a total of 62 preschool children with 6 staff members in four different classrooms.

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.
Today, LPA interviewed the director and gathered some information regarding the incident which was reported to our office on 2/24/2020.

Due to insufficient information available at this time, the reported incident needs further investigation. The incident will be concluded when all the information regarding the incident are available.

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. First level appeal is to Regional Manager, address is above on the report. Facility was advised on how to receive notifications for quarterly updates.
Exit interview was conducted with director.No deficiency was cited on today's date.
End of report.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2020
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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