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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370327
Report Date: 01/05/2021
Date Signed: 01/05/2021 12:52:14 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:117CENSUS: 43DATE:
01/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:DirectorTIME COMPLETED:
10:00 AM
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Tele-Investigation due to Covid-19 State of Emergency
On 1/5/2021 Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted a Tele- inspection via FaceTime to deliver the finding regarding a follow up unusual incident report which was self-reported to our office on 2/24/2020. LPA met with director, Ruth Larson remotely via FaceTime application. LPA notified the director that due to Covid-19 and Department of Public Health (DPH) guidelines of social distancing a tele inspection is conducted. The Covid-19 Emergency Response questionnaires were asked. There were 43 preschool children with 5 staff at the facility. A review of the Facility Personnel Report Summary on 1/5/2021 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. This is a follow up investigation which started initially on 3/2/2020. According to the self-report incident sent to our office, a 2-year-old child's representative brought it up to the director's attention that it was observed on the live video footage, a staff member pushed the child aside aggressively. This was observed by the child’s representative on the facility live video footage after the child was dropped off in the morning. LPA interviewed the director on the previous investigation date of 3/2/2020. The video tape was not available for review at the facility since the facility does not have control of rewinding or fast forwarding the tape. The Department requested the video footage to be sent to our office. The video footage received and reviewed from two angles of cameras in the classroom. The staff in question was observed walking in the classroom while holding the child's hand for few minutes. Later, staff had the 2-year-old child by her side while staff sitting in a chair in one corner of the classroom. The two-year-old child was standing next to the staff. Then, the staff stood up, moved quickly towards other children. It was observed on the video footage that staff member put her hand on the child's head slightly to move the child to the side so she could pass by the child to attend the other children on the other side of the classroom. No citation was issued. The Notice of Site Visit was not posted due to tele-investigation Covide-19 State of Emergency. Appeal Rights was explained. A copy of appeal rights (LIC 9058 1/16) will be provided through email and their signatures on this form acknowledges receipt of these rights. (The "Read Receipt" is in lieu of a signature). First level appeal is to Regional Manager, address is above on the report. Exit interview was conducted. This report ends here.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2021
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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