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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020851
Report Date: 02/27/2023
Date Signed: 02/27/2023 10:09:49 AM

Document Has Been Signed on 02/27/2023 10:09 AM - 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:EVERBROOK ACADEMY, LLCFACILITY NUMBER:
198020851
ADMINISTRATOR:FUENTEZ, TERESAFACILITY TYPE:
830
ADDRESS:520 W. BASELINE RD.TELEPHONE:
(909) 399-0081
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 26TOTAL ENROLLED CHILDREN: 25CENSUS: 21DATE:
02/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teresa FuentezTIME COMPLETED:
10:15 AM
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On 2/27/023 at 9:00 am Licensing Program Analyst (LPA), Carolyn Tuba conducted an unannounced Case Management visit to amend the LIC809-D to rectify and correct information provided on the citation given during the visit conducted on 2/24/2023 for a Case Management incident that had occurred on 2/16/2023 for Lack of Supervision. LPA met with the Director, Teresa Fuentez who guided LPA and a census of 21 children and 6 staff were present. A Covid Risk assessment had been conducted and LPA wore protected gear.

An exit interview was conducted, and a copy of this report was provided, along with Notice of Site Visit and Appeal Rights to the Director, Teresa Fuentez.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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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