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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494264
Report Date: 06/21/2022
Date Signed: 10/06/2022 10:19:01 AM

Document Has Been Signed on 10/06/2022 10:19 AM - 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:
3103141111
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 59DATE:
06/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Amy Siciliano, DirectorTIME COMPLETED:
11:00 AM
NARRATIVE
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****This is an amended version of a report a report that was created on 06/21/2022. The report is being amended to change the findings of the case management results.****

On 10/6/2022 9:57AM, Licensing Program Analyst (LPA) Miranda arrived at Maple Tree Academy WLA and met with Amy Siciliano, Director and informed the purpose of the visit. There are 51 children present with 7 Staff and Director.

On 06/21/2022 9:25AM, Licensing Program Analyst (LPA) Denise Miranda arrived 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 02/25/2022, The LIC 624 Unusual Incident /Injury Report (UIR) was received 3/3/2022 and assigned to LPA on 4/27/2022. 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 got the finger caught in the door at the entry/exit of the outdoor play area, facility applied first aid and contact parents immediately. Parents took the child to the doctor and got and x-ray which was determined it was a fracture to her finger. The pediatric orthopedic put cast on.

Per Title 22 Regulations and incident report was sent in timely manner and parent notified. Supervision policy was discussed in which the Director spoke and conducted staff meeting to all staff informing the teachers to be extra cautious when

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PRESCHOOL
FACILITY NUMBER: 197494264
VISIT DATE: 06/21/2022
NARRATIVE
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closing the doors, in addition children were also reminded to keep their hands and fingers away from the door while doors are being closed and opened. LPA reviewed teacher’s file and was observed that during the incident, facility had one fully qualified teacher, one teacher and one assistant with 24 children in care. Facility was in compliance with staff-children ratio and capacity limitation.

Per Director, LPA observed the incident area, located by the door at the first floor indoor and outdoor area


Based on interviews with staff and children and LPA’s observations, LPA Miranda finds that it does not appear that the incident was a result of Title 22 violation.

No citation were issue on this visit. The LIC809-D shall be dismissed.



This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

The licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed.


An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit was provided to Amy Siciliano, Director.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Denise Miranda
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
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document is an Amendment of Original Document on 10/03/2022 10:48 AM


Created By: Denise Miranda On 06/21/2022 at 12:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PRESCHOOL
FACILITY NUMBER: 197494264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/21/2022
Section Cited
CCR
101216.3(b)(1)

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** Deficiency Dismissed**
Teacher-Child Ratio- 101216.3 (b) The licensee may use teacher aides in a teacher-child ratio of one teacher and one aide for every 15 children in attendance. (1) A ratio of one fully qualified teacher (as specified in Section 101216.1(c)) and one aide for every 18 children in attendance in a preschool program is allowed when the aide meets the qualifications specified in Section 101216.2(d).

This requirement is
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Director agreed to provide a declaration today, how faciltiy will maintain Teacher-Child Ratio. A copy of title 22 101216.3 was provided to Director. Per Director on 6/22/22
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This requirement is not met as evidenced by: On 06/21/2022, LPA conducted a case management, due incident happened on 2/25/2022. Based on interviews, files reviewed it was found that during the incident facility had 1 full qualify teacher and 2 teachers aide (1 qualify and 1 not qualified) with 20 children in care. This is a Type A citation and poses immediately risk to the health and safety of children in care.
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 she will conduct a Lead Teacher and Director's meeting and 7/6/2022 Director will conduct an all Staff meeting that will be include on the top about Teacher-Child-Ratio. Copy of the meeting agenda, and staff sign in will be email to LPA Miranda no later than 7/7/2022.

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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


LIC809 (FAS) - (06/04)
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