304370328-9-24-2019-06-CC-MMAK-BGBTQU-20190924145631

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370328
Report Date: 09/24/2019
Date Signed: 09/24/2019 02:56:35 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 ACADEMY		FACILITY NUMBER:	304370328
ADMINISTRATOR:	LARSON, RUTH		FACILITY TYPE:	830
ADDRESS:	30722 RICHARD REESE WAY		TELEPHONE:	(949) 888-7274
CITY:	RANCHO SAN MARGARITA	STATE: CA	ZIP CODE:	92688
CAPACITY:	32	CENSUS: 19	DATE:	09/24/2019
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Assistant director		TIME COMPLETED:	01:30 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	Page 1 An unannounced annual inspection was conducted today by Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek who met with School Education Manager, Derek Weinmann in the office. The assistant director, Kim San Jose was supervising children in toddler room who joined during LPA's last hour. The director, Ruth Larson was not present on today's inspection. Census was taken and there were a total of 19 infants and toddlers with a total of 5 staff observed in two different classrooms. There were 3 napping infants with one staff in the crib area, and one staff with 4 awake infants in the activity area in the infant room. There were 12 toddlers with 3 staff in toddler room. There was another toddler room which was not in use at this inspection. A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The facility was reviewed to ensure compliance with license conditions and limitations, staffing and ratios, inaccessibility to poisons, medication, and hazardous items that can pose a danger to children. Equipment and furniture was inspected to ensure it's in good condition, free of sharp, loose or pointed parts. The bins had tight fitting covers. The napping area is separated from the activity area and has sufficient infant napping equipment. There is no walkers on the premises. The changing table is within the arm's reach of a sink. Bottles and dishes were checked in the refrigerator, they were labeled with the child's names and date. The infants and toddlers were being supervised. There are no weapons, firearms or bodies of water in the facility. The playground was inspected for safety, good condition of equipment, including appropriate cushioning material around and under high climbing equipment. Staff's files were reviewed for education verification, CPR/First Aid, infant/toddler units, and new immunization requirements for (MMR, Pertussis, and Flu vaccines). A sample of children's files were reviewed for completeness of medical assessment, and verification of sign in/out including time the child was signed in/out by authorized representative as well as verification of representatives full legal signature. Continued on page 2

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019

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: 304370328
	VISIT DATE: 09/24/2019

NARRATIVE

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LPA discussed the Incidental Medical Services (IMS) with the director. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. The facility has submitted an updated plan for providing Incidental Medical Services (IMS) to our office.
Mandated Reporter Training Certificates are on file for staff.

The Notice of Site Visit was posted. Facility representative was informed that 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 1/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. The facility representative was informed that they can refer to our Department website at www.ccld.ca.gov for obtaining the quarterly updates.
Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org

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 last inspection.
An updated pamphlet regarding safe sleep regulations in childcare and a pamphlet for lead poisoning facts were given to the staff in charge today.

In the areas that were evaluated, the facility was in compliance of the California Code of Regulations, Title 22, Division 12. No citation was issued today.

This report ends here.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2019

LIC809 (FAS) - (06/04)

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