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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197411901
Report Date: 09/30/2022
Date Signed: 09/30/2022 03:37:52 PM


Document Has Been Signed on 09/30/2022 03:37 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:MAPLE PRIMARY CENTER STATE PRESCHOOLFACILITY NUMBER:
197411901
ADMINISTRATOR:JUAREZ, ALFREDOFACILITY TYPE:
850
ADDRESS:3601 S. MAPLE AVE. RM. 100 105TELEPHONE:
(323) 232-0984
CITY:LOS ANGELESSTATE: CAZIP CODE:
90011
CAPACITY:48CENSUS: DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Sharyn Clark, Facility RepresentativeTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA) Denise Gibbs conducted an unannounced annual required inspection at the above facility on 9/30/22 at 1:20PM. LPA met with Sharyn Clark, Facility Representative (FR) who guided analysts on a tour of the facility.

There were 10 children and five staff present when LPA arrived. Facility is on the campus of Maple Primary Center in Room 100 and Room 105. Facility provides AM and PM program, 8AM to 11AM and 11:40AM to 2:40PM. All individuals present have obtained a criminal record clearance or criminal record exemption as a condition of employment with the Los Angeles Unified School District.

LPA toured Classroom Rooms 100 and 105. Classroom furniture was in good condition, free of loose, sharp and/or pointed parts. The floors and surfaces in the classrooms were clean and safe. Rugs were observed to be flat on the ground to avoid tripping hazards. Per FR, student use the water fountain outside the classroom. LPA informed that water must be available in the classroom for children to drink freely. FR stated that AM children bring water bottles and they will ask PM families to also bring in water bottles. Children have cubbies to store personal belongings. Children do not nap at facility due having part time programs. Per FR there is currently no children with medication in the classroom. Carbon monoxide detector is wired with smoke and fire alarm.

LPA toured the children’s restroom. Preschool children have their own restroom between room 100 and 105. Restroom was observed to be safe and sanitary with operable sinks and toilets.

LPA toured the outdoor play area. Outdoor area was observed to have age appropriate material for children. Preschool staff set up areas as needed. Preschool shares outdoor area with primary center children. Waiver on file for shared outdoor space. Shade was observed in the outdoor area. LPA observed operable water fountains outdoors for children to drink freely. ---------------------PAGE 1
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: MAPLE PRIMARY CENTER STATE PRESCHOOL
FACILITY NUMBER: 197411901
VISIT DATE: 09/30/2022
NARRATIVE
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 LPA reviewed Sign In/Out sheets. LPA observed that one child in classroom 100 was not on the sign in sheet. Per FR this child is part of the Preschool Collaborative(PCC program). LPA informed that all children in the licensed preschool program must be signed in/out with guardians full signature, time and date.

LPA observed required posted documentation which included, Facility License, Publication (PUB) 393- Notification of Parent Rights, PUB 269- Child Passenger Restraint System, Licensing Form LIC 613A- Notification of Personal Rights, Daily Schedule and Lunch/Snack Menu in the preschool classroom. Menu was discussed.

Facility records were reviewed for 9148- Earthquake Preparedness form, LIC9040- Children's Roster and (LIC) 610- Facility Disaster Plan. Disaster drill was last drill conducted 8/18/22. Disaster Plan was discussed.

Children’s records were reviewed for Emergency Card with signed medical consent, Immunization Records, LIC 995 Notification of Parents’ Rights, LIC 701- Physician’s Report, LIC 613A- Personal Rights, and signed Admissions Agreement. Documents were discussed.

Staff records were reviewed at for approved Pediatric First Aid and CPR certification for one staff, LIC 9052- Employee Rights, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse, Transcripts or Permit for certified teacher and current Mandated Reporter Training Certificate. LPA observed that two out of four preschool staff are missing immunization record and mandated reporter training.

At LPA observed the kitchen located on the primary center campus. Facility provides Breakfast and Lunch. Food is not cooked at the facility. Prepackaged food is delivered daily. Extra food is stored is discarded daily. Kitchen was observed to be clean, free of litter, insects and rodents. All trash cans have tight fitting lids for solid waste. Cleaning supplies are stored separate from the food.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

----------------------PAGE 2
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: MAPLE PRIMARY CENTER STATE PRESCHOOL
FACILITY NUMBER: 197411901
VISIT DATE: 09/30/2022
NARRATIVE
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LPA observed that facility is implementing COVID-19 precautions and procedures as required by Los Angeles Unified School District and the Department of Public Health.

Incidental Medical Services (IMS):
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Facility representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Facility Representatives, Sharyn Clark.


--------------------------PAGE 3
SUPERVISOR'S NAME: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/30/2022 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: MAPLE PRIMARY CENTER STATE PRESCHOOL
FACILITY NUMBER: 197411901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239.2(a)
Drinking Water
(a) Drinking water from a noncontaminating fixture or container shall be readily available both indoors and in the outdoor activity area.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview) (record review, the licensee did not comply with the section cited above. Water was not obsered in the classroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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FR states, parents will be asked to bring in water bottles and if parents forget a back up plan will be Arrowhead gallon with a spout and cups for students to drink freely. FR will send a picture to LPA by POC date 10?28/22.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of four staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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FR states that she will have her staff bringin their immunization records and send copies to LPA by POC date 10/28/22.

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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/30/2022 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: MAPLE PRIMARY CENTER STATE PRESCHOOL
FACILITY NUMBER: 197411901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of four staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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FR states, staff took training and she will email LPA by POC date 10/28/22
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Trevino CochranTELEPHONE: (323) 981-3385
LICENSING EVALUATOR NAME: Denise GibbsTELEPHONE: (323) 558-2794
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5