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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494264
Report Date: 06/21/2022
Date Signed: 06/21/2022 03:36:45 PM


Document Has Been Signed on 06/21/2022 03:36 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:MAPLE TREE ACADEMY WLA PRESCHOOLFACILITY NUMBER:
197494264
ADMINISTRATOR:AMY SICILIANOFACILITY TYPE:
850
ADDRESS:2920 S SEPULVEDA BLVDTELEPHONE:
(310) 314-1111
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY:80CENSUS: 59DATE:
06/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amy Siciliano, DirectorTIME COMPLETED:
01:30 PM
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On 06/21/2022 11:00AM, Licensing Program Analyst (LPA) Denise Miranda conducted a case management - incident inspection at Maple Tree Academy WLA Preschool, located at 2920 S. Sepulveda Blvd, Los Angeles, CA 90064, for the purpose of following up on the self-reported unusual incident that occurred at the facility on 04/29/2022, The LIC 624 Unusual Incident /Injury Report (UIR) was received 5/11/2022. LPA met with Director Amy Siciliano and informed the purpose of the visit. There are 59 children present with 8 teachers and Director.

Per report child#1 was balancing on the wooden balance beam and lost balance, fell and bumped the head on the corner of the wooden beam. Teacher#1 immediately was provided care and supervision, first aid and parents were immediately contact.

During this inspection, LPA conducted an interviews with facility staff, child and child's parent and other pertinent. LPA also obtained a copy of the facility sign in and sign out sheet dated 04/29/2022.


Based on the information obtained throughout the course of the investigation, it does not appear that the incident was a result of a Title 22 violation. Facility staff provided proper care and supervision during the time of the incident. The facility also followed Title 22 Regulations in reporting the incident to the Community Care Licensing Division.

An exit interview was conducted and a copy of this report along with the Notice of Site Visit and an advisory notes were provided to Amy Siciliano, Director.

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3068
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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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