304370327-2-18-2020-06-CC-PMAA-BMML4F-20200312082524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 304370327
Report Date: 02/18/2020
Date Signed: 02/18/2020 02:44:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2019 and conducted by Evaluator Mahnaz Malek

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20191227142526

FACILITY NAME:	EVERBROOK ACADEMY		FACILITY NUMBER:	304370327
ADMINISTRATOR:	LARSON, RUTH		FACILITY TYPE:	850
ADDRESS:	30722 RICHARD REESE WAY		TELEPHONE:	(949) 888-7274
CITY:	RANCHO SAN MARGARITA	STATE: CA	ZIP CODE:	92688
CAPACITY:	117	CENSUS: 60	DATE:	02/18/2020
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff dropped child on cot
Staff pushed child from coming closer to staff
Staff grabbed child by the shirt collar

INVESTIGATION FINDINGS:

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This is a follow up investigation regarding the above complaint allegations which LPA had started on 1/3/2020. LPA met with director, Ruth Larson. Census was taken. There were a total of 60 preschool children with 6 preschool staff in 4 different classrooms. The staff or individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
It was reported to our office that a live video footage from a child's classroom was viewed showing staff # 2 was carrying child # 1, dropping child onto mat. The reporting party also viewed staff # 2 reading to the whole class, child # 1 was scooting toward staff # 2 telling something to the child causing child to jump back. Child tried to scoot toward staff #2 again but child was pushed with staff # 2's hand causing child to fall backwards. Reporting party stated these incidents happened on 12/20/2019.
Reporting party also stated there was an incident where observed on live video that staff # 2 grabbed child
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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

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 7

Control Number 06-CC-20191227142526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/18/2020

NARRATIVE

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# 1 by the back of child's shirt collar and shook child on 11/8/19.

On the last investigation date of 1/3/2020 LPA interviewed three staff and gathered some documents. During the course of investigation, LPA interviewed the subject staff over the phone. Our office requested a copy of the video footage with the dates and estimated times the reporting party had mentioned. The video footage was viewed. The video footage shows the children during nap time from two different angels on 12/20/2019, and after nap towards the end from two different angels on 12/20/2019, and October 24, 2019.

LPA viewed on this video footage that on one incident, staff # 3 pulls two children's arms and drops children on the cot in a rough manner on 12/20/2019 during nap time. On another incident toward the late afternoon, LPA observed on the video footage that staff # 2 pushed child # 1 back two times in a rough manner sitting child in the circle time preventing child # 1 to get closer to staff # 2 on 12/20/2019. On another incident of 10/24/2019 LPA viewed on the video footage that staff # 2 lifted child # 1 from the chair while sitting by the child's back of shirt collar and lifted child's left arm up in the air in a rough manner. Then it was observed staff # 2 dropped the child on the floor, picked the child up, held the child very close to staff's face talking to the child.

Based on LPA's viewing details of these video footage and the interviews which were conducted with six staff including the subject staffs, and reviewing the documents, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter 12, is being cited on the attached LIC 9099 D for the deficiency section 101223(a)(1) for Personal Rights violation.

During the course of investigation and viewing the video footage of the above incidents, LPA observed a child went to the restroom without any staff supervising the child visually. It was estimated the child was in the bathroom for 4 minutes while staff # 2 and staff # 3 were away from the bathroom without having any visual observation on the child. (The two angels of the video footage were viewed for this purpose). Also it was observed few children were hitting each other and staff # 2 did not intervene. California Code of Regulations,
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SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 06-CC-20191227142526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/18/2020

NARRATIVE

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Title 22, Division & Chapter 12, is being cited on attached LIC 9099D for deficiency section 101229(a) for Lack of supervision violation.

Also during the course of investigation, LPA learned that the incidents of 10/24/2019 and 10/20/2019 regarding personal rights violation of children were not reported to our Department as it was required by the Department. California Code of Regulations, Title 22, Division & Chapter 12, is being cited on the attached LIC 9099 D for the deficiency section 101212(d) for Reporting Requirements violation.

Notice of Site Visit was posted. 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 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional Manager; address is above on the report.

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 and lead poisoning flyer were given to the facility representative on the previous investigation date.

Upon receipt, licensee shall post and provide copies of this report to parents/Guardians of children in care and to parents/guardians of children newly enrolled at the facility during the next 12 months. Licensee may use LIC 9224. Exit interview was conducted.

Tehr report ends here.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

LIC9099 (FAS) - (06/04)

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Control Number 06-CC-20191227142526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/18/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/19/2020 Section Cited CCR 101223(a)(1)	1 2 3 4 5 6 7	Persoal Rights- Each child to be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by LPA viewing a video footage during nap time showing staff # 3 pulls two children's arms and drop the children on the cot in a rough manner. Staff # 2 pushed/scooted child # 1 back two times on the floor in a rough	1 2 3 4 5 6 7	The director stated one of the staff does not employ at the facility any longer. The director will review the section of personal rights of children with staff and have staff watch the video regarding the personal rights on about the E-Learning Modules available at https://ccld.childcarevideos.org on
	8 9 10 11 12 13 14	manner to sit the child. Staff # 2 lifted child # 1 by child's collar from the chair and lifted child's left arm up in the air in a rough manner. Then Staff # 2 dropped the child on the floor, picked the child up, held the child very close to face talking to the child. The licensee failed to meet the Licensing Regulations. This is an immediate hazard to the health and safety of children in care.	8 9 10 11 12 13 14	www.ccld.ca.gov The director will send staffs' names and signatures acknowledging reviewing this section with them to our office by the due date.
Request Denied Type A 02/19/2020 Section Cited CCR 101229(a)	1 2 3 4 5 6 7	Responsibility for providing care and supervision- The licensee shall provide care and supervision as necessary to meet the children's needs. This requirement was not met as evidenced by LPA viewing a video footage of children dated 12/20/2019. A child was observed using the restroom while staff # 2 and 3 being in the classroom away from the	1 2 3 4 5 6 7	The director will review the section of supervision of children with staff and have staff watch the video regarding the Responsibility for providing care and supervision about the E-Learning Modules available at https://ccld.childcarevideos.org on
	8 9 10 11 12 13 14	restroom without any visual observation of the child. This was estimated 4 minutes. Also it was observed children were hitting each other while staff # 2 was not intervening. The licensee failed to meet the Licensing Regulations. This is an immediate hazard to the health and safety of children in care.	8 9 10 11 12 13 14	www.ccld.ca.gov The director will send staffs' names and signatures acknowledging reviewing this section with them to our office by the due date.

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: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 06-CC-20191227142526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/18/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/20/2020 Section Cited CCR 101222(d)	1 2 3 4 5 6 7	Reporting Requirements- Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.	1 2 3 4 5 6 7	According to director, she reported the incidents to her superior. The director stated she would send an statement acknowledging the importance of Reporting Requirements to be reported in a timely manner to complying with Licensing Regulations. She will send the statement to our office by the due date.
	8 9 10 11 12 13 14	This was not met as evidenced by LPA's learning during the course of investigation that the incidents of 10/24/2019 and 10/20/2019 were not reported to our Department as it was required by the Department. The licensee failed to meet the Licensing Regulations. This is a potential hazard to the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2019 and conducted by Evaluator Mahnaz Malek

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20191227142526

FACILITY NAME:	EVERBROOK ACADEMY		FACILITY NUMBER:	304370327
ADMINISTRATOR:	LARSON, RUTH		FACILITY TYPE:	850
ADDRESS:	30722 RICHARD REESE WAY		TELEPHONE:	(949) 888-7274
CITY:	RANCHO SAN MARGARITA	STATE: CA	ZIP CODE:	92688
CAPACITY:	117	CENSUS: 60	DATE:	02/18/2020
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff physically blocking child from interacting with other children

INVESTIGATION FINDINGS:

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Page 1 of 2

This is a follow up investigation regarding the above complaint allegation which had been started on 1/3/2020. LPA met with director, Ruth Larson. Census was taken. There were a total of 60 preschool children with 6 preschool staff in four different classrooms. The staff or individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
It was reported to our office during viewing a live video footage from a child's classroom some children reading at the table but when child # 1 tried to go to the table, staff # 2 blocked child # 1 with body so child could not get to the table.
On the last investigation date of 1/3/2020 LPA interviewed three staff and gathered some documents. During the course of investigation, LPA interviewed the subject staff over the phone. Our office requested a copy of the video footage from the facility. The video footage was viewed. The video footage shows staff # 2 was
Continued on page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 06-CC-20191227142526

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/18/2020

NARRATIVE

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putting the toys back on the shelf. Child # 1 was getting close to the shelf. Staff # 2 guided the child to the other section of the classroom. Based on the viewing of the video footage received from the facility, the interviews which were conducted with six staff including the subject staff, reviewing the documents, and information gathered, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Notice of Site Visit was posted. 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 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional Manager; address is above on the report.

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 previous investigation date.

Page 2 ends here.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020

LIC9099 (FAS) - (06/04)

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