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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304370328
Report Date: 08/13/2019
Date Signed: 08/13/2019 05:31:57 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
06/17/2019 and conducted by Evaluator Gesine Connolly
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20190617130256
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:
08/13/2019
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ruth Larson TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff gave an infant a bottle that did not belong to them
Facility operated out of ratio
Facility staff did not supervise infants - remained on cell phone
INVESTIGATION FINDINGS:
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A subsequent complaint inspection was made today by Licensing Program Analyst (LPA) Connolly. At the time of arrival the LPA met with the director, Ruth Larson, who accompanied the LPA on a tour of the infant center. Census was taken. There were 16 infants in care with four attending staff.
A review of staff records 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.

The LPA has made this subsequent inspection due to the above allegations received in the licensing office 6/17/19. The director was informed today that during the course of this investigation four staff have been interviewed and record reviews have been conducted for the documentation provided by the facility: infant and staff attendance sheets for two weeks of the month June 2019 and a copy of a self reported incident in which an infant in care was provided with another infant's bottle.
The director was informed that based on these interviews and document reviews the above allegations
continued on page two
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
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
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
06/17/2019 and conducted by Evaluator Gesine Connolly
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20190617130256

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:
08/13/2019
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ruth Larson TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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2
3
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9
Facility staff handled child in a rough manner
Facility staff co-mingled children
Facility staff did not follow infants feeding plan
INVESTIGATION FINDINGS:
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A subsequent complaint inspection was made today by Licensing Program Analyst (LPA) Connolly. At the time of arrival the LPA met with the director, Ruth Larson, who accompanied the LPA on a tour of the infant center. Census was taken. There were 16 infants in care with four attending staff.
A review of staff records 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.
Return inspection is made due to the above allegations received in the licensing office 6/17/19.

During the course of this investigation four staff have been interviewed. The facility has provided a copy of infant and staff attendance sheets for two weeks of the month June 2019.

The director was informed that based upon these interviews and document reviews there is not a preponderance of evidence to either support or negate the complaint allegations. They are therefore, determined be unsubstantiated. Continued on page two

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
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-20190617130256
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: 304370328
VISIT DATE: 08/13/2019
NARRATIVE
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Page two
There was not a preponderance of evidence to support the allegation infants in care are handled in a rough manner.

In regard to the allegation facility staff co-mingled children the investigation showed that Infants, children under the age of two, attending the toddler room have on occasion co mingled with the infants in the infant room. There was not a preponderance of evidence that children in another program co/mingled with the infants.

In regard to the allegation facility staff did not follow infants feeding plan the investigation showed that infant feeding plans are posted in the infant room and a computer system is in place to provide the family daily information as to how the plan is being followed for the infant in care. There was not a preponderance of evidence to substantiate the allegation facility staff did not follow an infants feeding plan.

The director was informed that 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. No deficiencies are cited.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) 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 the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result civil penalties of $100.00. The 'Notice of Site Visit' must be posted on or adjacent tot he door. Failure to post Type A reports for 30 days will result in a civil penalty of $100.00.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 06-CC-20190617130256
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: 304370328
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2019
Section Cited
CCR
101416.5(b)
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Staff-Infant Ratio: There shall be a ratio of one teacher for every four infants in attendance. This regulation is not met as evidenced through staff interviews which disclosed that during certain times of the day such the gathering time staff have been left caring for more than four infants.
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The director who said she will have a staff meeting in which this regulation will be addressed said the staff meeting minutes with the signatures of the attending staff will be submitted to the licensing office by the due date 8/14/19.
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 This poses an immediate risk to the health and safety of infants in care.
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LPA provided email address.
CCR
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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.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 06-CC-20190617130256
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: 304370328
VISIT DATE: 08/13/2019
NARRATIVE
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Page two
have been substantiated.
The self reported incident in which one infant was provided with a bottle designated for another infant was verified.
Staff interviews disclosed that during certain periods of the day staff are left caring for more than four infants. This substantiates the allegation facility has operated out of ratio.

Through documentation review and staff interviews it was disclosed that there was a staff member who used a personal cell phone while assigned to provide care and supervision in the infant room. Thus the allegation facility staff did not supervise infants - remained on cell phone was substantiated.

The director was informed that based upon LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are met, therefore, the above allegations are found to be substantiated. California Code of Regulations Title 22, Division 12, Sections 101223(a)(2), 101416.5(b) and 101429(a)(1) are cited on the attached LIC 9099 Ds.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) 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. If the facility receives a Type 'A' violation the director shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC9224) signed by parents in each child’s file.

The facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result civil penalties of $100.00. The 'Notice of Site Visit' must be posted on or adjacent tot he door. Failure to post Type A reports for 30 days will result in a civil penalty of $100.00.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 06-CC-20190617130256
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: 304370328
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2019
Section Cited
CCR
101223(a)2)
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Personal Rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This regulation is not met as evidenced by interviewing staff and reviewing documentation. The facility self reported an infant in care received a bottle designated for
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The director who said she will have a staff meeting in which this regulation will be addressed said the staff meeting minutes with the signatures of the attending staff will be submitted to the licensing office by the due date 8/14/19.
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another infant in care. The allegation facility staff gave an infant a bottle that did not belong to them is substantiated. This occurrence posed a potential risk to the health and safety of an infant in care.
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LPA provided email address.
Type B
08/14/2019
Section Cited
CCR
101429(a)(1)
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Responsibility for Providing Care and Supervision for Infants. Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. This regulation is not met as evidenced by staff interviews and documentation review that showed
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The director who said she will have a staff meeting in which this regulation will be addressed said the staff meeting minutes with the signatures of the attending staff will be submitted to the licensing office by the due date 8/14/19.
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a staff member remained on a personal self phone while assigned to provide care and supervision to infants present in the infant room. This lack of supervision by this one staff member posed a potential risk to the health and safety of infants 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.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
LIC9099 (FAS) - (06/04)
Page: 6 of 6