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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494263
Report Date: 11/25/2020
Date Signed: 11/25/2020 04:55:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:MAPLE TREE ACADEMY WLA-INFANTFACILITY NUMBER:
197494263
ADMINISTRATOR:CASPIAN, AMIRFACILITY TYPE:
830
ADDRESS:2920 S SEPULVEDA BLTELEPHONE:
3103141111
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY:70CENSUS: 36DATE:
11/25/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Amy Siciliano, Director Assistant TIME COMPLETED:
04:40 PM
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On 11/25/2020 LPA conducted a Complaint 10-visit, control# 30-CC-20201120153956, under preschool program, Licensing Program Analyst Denise Miranda met with Amy Siciliano, Director Assistant. Per Ms. Siciliano, Mr. Amir Caspian, Director was not present.

LPA provided an advisory note, regarding documents that facility shall provide to qualify a new a Director. Facility shall mail or drop off the New Director documents to El Segundo Regional Office, no later than 12/07/2020.

An exit interview was conducted, and a copy of this report and an advisory note was provided to Director Assistant Ms. Amy Siciliano, for review.

SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
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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