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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426203097
Report Date: 11/15/2022
Date Signed: 11/15/2022 12:41:53 PM


Document Has Been Signed on 11/15/2022 12:41 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117



FACILITY NAME:CAC - MAPLE CENTERFACILITY NUMBER:
426203097
ADMINISTRATOR:ANGELA MCQUITERFACILITY TYPE:
850
ADDRESS:120 W. MAPLETELEPHONE:
(805) 736-7574
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:40CENSUS: 13DATE:
11/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:See YangTIME COMPLETED:
12:45 PM
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On 11/15/2022 at 12:35 PM Licensing Program Analyst (LPA) Rosie Breault conducted an unannounced Case Management – Incident inspection and met with Teacher See Yang of the abovementioned facility. LPA informed teacher of the purpose for the inspection and completed a COVID-19 pre-screening questions prior to the commencement of the inspection. LPA, along with teacher toured the facility, inside and outside. There were thirteen (13) children in care and four (4) staff.

This is an inspection of a self-reported unusual incident which reported Community Care Licensing (CCLD) by Director Carly Velasquez on September 16th, 2022 in which a child had reported to parent “oh god take these nasty teacher away” and that a teacher had grabbed child by arm and pushed back on bed to sleep. Per Director in usual incident, no staff witnessed this incident occur.

During inspection, Teacher Yang stated parent reported it to Director Carly Velasquez and had a meeting with parent and teacher. Not sure what become of it. LPA requested Teacher to contact director via phone to discuss incident; however unavailable. Teacher contacted Maria Douvias, Regional Manager (RM) for LPA to speak with. Per RM, Director and Associate Director were informed right away; however, did not fit the profile for the teacher’s behavior and no staff witnessed and child has good (prior and current) relationship with teacher. RM stated meeting occurred with parent, teacher, and director. Child is currently enrolled, and no further issues have been reported with the teacher. LPA requested RM to provide detailed email of meeting that occurred by Friday 11/18/2022.

There were no deficiencies cited during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Teacher

SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Maryrose BreaultTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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