304370327-8-25-2022-06-CC-PRIS-CHMQN2-20220825121825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370327
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:18:58 PM

Document Has Been Signed on 08/25/2022 12:18 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

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: 45	DATE:	08/25/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Kim San Jose, Asst Director		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LIcensing Program Analysts (LPA) P Rivas and D Valdez-Santana conducted a case management visit to investigate a self-reported incident that occurred on or about 08/17/22. The Unusual Incident report has it listed as 08/17/22 based on when Director spoke with Child#(C1's) parent. A review of facility Personnel Report Summary on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Assistant Director, Kim San Jose was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. During today's visit LPAs conducted a walk through of this facility and took census; Preschool room had 9 children and 1 teacher; Pre-K rooms had 2 teachers and 20 children; 2year old's Rooms had 16 children and 2 teacher LPA interviewed three staff, one child and Asst Director. LPA reviewed one staff file and one child's file. LPA is requesting copies of LIc 500, code of conduct, Camera footage of outside prek-Kindergarten playground for Monday 08/15/22 from 4:55pm to 5:10pm, Complete Roster by 09/02/22 Due to time constraints, further investigation is required. cont. page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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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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: 08/25/2022

NARRATIVE

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An exit interview was conducted with Asst Director Ms. San Jose. Appeal Rights were explained. The Asst. Director was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat Rivas	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC809 (FAS) - (06/04)

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