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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304370328
Report Date: 10/15/2025
Date Signed: 10/15/2025 03:44:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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
09/25/2025 and conducted by Evaluator Mahnaz Malek
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20250925143321
FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
304370328
ADMINISTRATOR:LARSON, RUTHFACILITY TYPE:
830
ADDRESS:30722 RICHARD REESE WAYTELEPHONE:
(949) 888-7274
CITY:RANCHO SAN MARGARITASTATE: CAZIP CODE:
92688
CAPACITY:32CENSUS: 16DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Assistant directorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Sick children are not isolated when get sick
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted a follow up investigation regarding the above allegation. This is a follow-up for the visit conducted on 9/29/2025. LPA met with assistant director, Shipra Shrivastava. LPA observed 7 infants with 3 staff in the infant room, and 9 toddlers with 3 staff in Toddler Room 2. Toddler Room 1 was not in use.

A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.
On 09/25/2025, the Orange County Child Care Office received a complaint alleging 1) Sick children are not isolated when get sick.
The reporting Party (RP) reported that it was observed a child in the infant room was sick, child was picked up after a while without the child being isolated.
Continued on page 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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 6
Control Number 06-CC-20250925143321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 304370328
VISIT DATE: 10/15/2025
NARRATIVE
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Page 2 of 2

During the course of investigation, LPA interviewed eight (8) staff members who work in the infant/toddler program. Staff stated that they sometimes isolate children and sometimes sick children stay in the classroom until parents come and pick up their children. Sometimes it might take a while for parents to be reached out . Therefore, the sick child stays in the infant room until child is picked up. However, on the initial inspection date of 9/29/2025 during the inspection of infant room, LPA observed a child in the infant room. According to staff member, child was sick. LPA was informed by staff member that the child had blisters on the hand and bottom. Staff stated child might have Hand, Foot, and Mouth disease. Child's representative was called but the child was not isolated from the other children.

Based on interviews with eight (8) staff members from infant/toddler program, LPA's observation dated 9/29/2025, and contacting 10 random parents of whom 3 responded with no concerns regarding the allegation, it was determined the preponderance of evidence standard has been met, the allegation of 1) Sick children are not isolated when get sick is found to be SUBSTANTIATED. Therefore, California Code of Title 22 Regulations Section 101426.2(a)(b) under Infant Care Isolation for Illness is cited on next page (9099D)

The assistant director, Shipra Shrivastava was provided with a copy of their appeal rights (LIC 9058) 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. Notice of Site Visit was posted. The notice of the site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The exit interview was conducted with the assistant director, Shipra Shrivastava.

End of report.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 06-CC-20250925143321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 304370328
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2025
Section Cited
CCR
10423.6(a)(b)
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Infant Care Isolation for Illness- (a) In addition to Section 101226.2, the following shall apply:
(b) The isolation area shall be equipped with a crib, cot, mat or playpen for each ill infant. The above section was not met as evidenced by interviewing 8 staff in the
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The assistant director agreed to send a plan that children who are sick will be isolated from the other children. The plan will be sent to LPA's email address by the due date of 10/20/2025
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infant/toddler program and LPA's observation on the inspection date of 9/29/2025 that a child who was sick in the infant room was not isolated from the other children. This is a potential risk to the health and safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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
09/25/2025 and conducted by Evaluator Mahnaz Malek
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20250925143321

FACILITY NAME:EVERBROOK ACADEMYFACILITY NUMBER:
304370328
ADMINISTRATOR:LARSON, RUTHFACILITY TYPE:
830
ADDRESS:30722 RICHARD REESE WAYTELEPHONE:
(949) 888-7274
CITY:RANCHO SAN MARGARITASTATE: CAZIP CODE:
92688
CAPACITY:32CENSUS: 16DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Assistant directorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Children get exposed to chemicals in the classroom
Classroom is out of ratio
INVESTIGATION FINDINGS:
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Page 1 of 2
Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted a follow up investigation regarding the above allegation. This is a follow-up for the visit conducted on 9/29/2025. LPA met with assistant director, Shipra Shrivastava. LPA observed 7 infants with 3 staff in the infant room, and 9 toddlers with 3 staff in Toddler Room 2. Toddler Room 1 was not in use.

A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.
On 09/25/2025, the Orange County Child Care Office received a complaint alleging 1) Children get exposed to chemicals in the classroom, 2) Classroom is out of ratio.

The Reporting Party (PR) reported that janitorial staff will be helping teachers in the classroom and R/P is
Continued on page 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 06-CC-20250925143321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 304370328
VISIT DATE: 10/15/2025
NARRATIVE
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Page 2 of 3

concerned of children being exposed to chemicals. It was also reported that it was observed 5 infants with one staff on 9/24/2025 before noon and reported last week, it was observed one teacher with 5 to 6 children alone in the classroom before noon. The date and the name of the staff are unknown.

During the course of investigation, the LPA interviewed eight (8) staff members who work in the infant/toddler program. LPA contacted 10 random parents of whom 3 parents responded. Children were not interviewed due their age being young and not qualified. LPA also reviewed the time sheet for staff for the week of 9/15/2025 and 9/22/2025, and face to name records of children for those two weeks.

Regarding the allegation of "Children get exposed to chemicals in the classroom"

During interviews with eight (8) staff members from infant/toddler program, the LPA was told that staff members clean their classrooms with the solution of water and soap, water, bleach and water throughout the day. They do not use the strong chemicals when children around. The staff member stated they wear gloves when feed children. They stated the janitorial staff who is helping also in the classroom has different scheduling. LPA interviewed staff # 1 (S1) who stated S1 has two different tasks. One is to help in the classroom and one is to clean the classroom. S1 stated that the scheduling of cleaning and working in the classroom are not at the same time. Once S1 is done with classroom duty, S1 changes clothes and does the cleaning tasks. S1 stated S1 is not using chemicals when children are around. All the products S1 is using are safe for children. Staff members confirmed the chemicals are not used during children's presence. They stated the products are safe for children anyway. Staff stated they are careful not to use the chemicals around children. They said normally cleaning is at the end of the day.
Out of 10 random parents contacted, three parents responded with no concerns regarding this allegation.

Regarding the allegation of "Classroom is out of ratio"
During interviews with eight (8) staff members from infant/toddler program, the LPA was told that staff members notify the management if the number of children increases and they need additional staff to cover the ratio. Two staff stated they open the infant room at 7:00 am and number of children do not reach to 8 children before the 3rd staff arrives.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 06-CC-20250925143321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 304370328
VISIT DATE: 10/15/2025
NARRATIVE
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Page 3 of 3

A few staff member stated sometimes couple of parents arrive at the same time, they call the management to send additional staff. Staff members stated the management can handle sending additional staff very well. LPA realized the staff have knowledge regarding teacher child ratio which is 1:4.
They stated they keep an eye on the teacher child ration throughout the day. Staff did not confirm being out of ratio in the infant room.
LPA reviewed the face to name of children's record for the week of 9/15/2025 and week of 9/22/2025 and the time cards of the staff for the same dates. However, the name to face attendance sheets were not adequately accurate and complete in some areas. Out of 10 random parents contacted, three parents responded with no concerns regarding this allegation.

Based on interviews with eight (8) staff members from infant/toddler program, reviewing documents, and contacting 10 random parents (with 3 responses) with no concerns regarding the allegations , there is not enough evidence and witness to support the occurrence of the above allegations. This agency has investigated the complaint alleging, 1) Children get exposed to chemicals in the classroom, 2)
Classroom is out of ratio , “although the allegations may have happened or are valid, there is not a preponderance of evidence to prove, the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

The assistant director, Shipra Shrivastava was provided with a copy of their appeal rights (LIC 9058) 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. Notice of Site Visit was posted. The notice of the site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The exit interview was conducted with the assistant director, Shipra Shrivastava.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6