304370327-3-25-2024-06-CC-MMAK-D3PR74-20240325124544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370327
Report Date: 03/25/2024
Date Signed: 03/25/2024 12:45:48 PM

Document Has Been Signed on 03/25/2024 12:45 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
ORANGE CO CHILD CARE, 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: 65	DATE:	03/25/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Director		TIME COMPLETED:	01:15 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	Page 1 of 2 Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek conducted an onsite case management inspection for the purpose of checking into an incident that the facility self reported to our office on 3/19//2024. LPA met with director, Ruth Larson. LPA took census. There were a total of 65 preschool children with 7 staff in four different classrooms. According to the self incident report, 2 year old child started crying while standing next to a table and a shelf. Staff # 1 noticed the child had a bump on the left side of the forehead near eyebrow. A review of the Facility Personnel Report Summary on this date indicates 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, staff # 1 and staff # 2 who had knowledge regarding the incident. Staff # 1 stated staff had a group of children near by while staff was standing close to the area where the incident happened. Staff # 1 stated staff had the group of children under supervision when staff heard child # 1 was crying. Staff # 2 stated staff was on the other side of the classroom with other group of children when staff heard the child was crying. According to staff # 1 child lost balance and fell while hitting the side of the forehead near eyebrow on the corner of the table. The facility stated they had the incident on the video footage and the management had reviewed it. LPA requested to watch the video footage. They agreed. LPA, the director, Ruth Larson and the District Manager, De Anne McCashland watched the video footage through a video call at the same time at the facility. LPA observed staff # 1 was standing around few children including child # 1 when the child accidentally lost balance and fell and hit forehead on the left side at the corner of the children's table. Child # 1 got medical attention. There was a cut not too deep to get stiches. Continued on page 2

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 703-2741
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: EVERBROOK ACADEMY	FACILITY NUMBER: 304370327
	VISIT DATE: 03/25/2024

NARRATIVE

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The child was back to school the next day. This was an unfortunate incident that happened to child # 1 when lost balance and fell while standing and hit the forehead on the corner of the children's table. It happened so quickly that the staff could not have done anything to prevent it.
Children including child # 1 were not being interviewed due to their age being too young.

Based on the interviews with the director, two present staff in the classroom at the time of the incident, and reviewing the video footage of the incident dated 3/19/2024 the incident was not fount out to be due to lack of staffs' supervision.

In the areas that were evaluated, no deficiency was observed of the California Code of Regulations, Title 22, Division 12 on this inspection.

A notice of site visit was given to director, Ruth Larson and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to post will result in Civil Penalties of $100.00.

Exit interview conducted and report was reviewed with the director, Ruth Larson.

End of report

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 703-2741
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC809 (FAS) - (06/04)

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