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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494263
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:42:12 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:STEPHANIE CHACON MEDINAFACILITY TYPE:
830
ADDRESS:2920 S SEPULVEDA BLTELEPHONE:
(310) 314-1111
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY:70CENSUS: 28DATE:
12/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Stephanie Chacon, Director TIME COMPLETED:
01:55 PM
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On 12/22/2021 at 1:31PM, Licensing Program Analyst (LPA) Denise Miranda conducted an unannounced case management- incident at Maple Tree Academy WLA – Infant, located at 2920 S. Sepulveda, CA 90064 for the purpose of following up on the unusual incident that was reported via email on 10/20/2021. LPA informed to the Director, Stephanie Chacon the purpose of this visit. There are 28 infants with 6 staff and Director.

According with the first report ( form: LIC624), received on 10/20/2021, facility did not provide clients name, age of the infants and number of cases.
On 12/02/2021, it was found that facility had 10 cases of Hand, Foot and Mouth Disease and a revised lic624 Unusual Incident Report was requested. According to the revised report (LIC624, received on 12/10/2021, on 10/18/2021 (2 cases occurred), on 11/21/2021 (4 cases occurred) and 11/24/2021 (4 cases occurred). Facility had a the total of 10 cases of Hand Foot and Mouth Disease.
Per facility’s revised report, the infants were first quarantined. Parents were notified to pick-up immediately. Children with signs and symptoms were instructed to remain home until they were asymptomatic, minimum 72 hours. All surfaces, toys and materials/furniture were sanitized and disinfected. Teachers were instructed to do checks of all children for signs and symptoms frequently throughout the day.
Stephanie Chacon, Director attempted to call the health department on 12/01/21 to inform them of the outbreak. On 12/09/2021 Facility reported via email to Health Department regarding the outbreak that occurred on 10/18/2021, 10/21/2021 and 10/24/2021.
On 12/22/2021 a technical violation regarding report requirement, was issued and provided to Director.
An exit interview was conducted and a copy of this report and Notice of Site Visit were provided to Stephanie Chacon, Director.
SUPERVISOR'S NAME: Peter FloresTELEPHONE: (424) 301-3077
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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