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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020155
Report Date: 04/05/2024
Date Signed: 04/05/2024 02:58:33 PM

Document Has Been Signed on 04/05/2024 02:58 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:MUSE ACADEMY INC., THEFACILITY NUMBER:
198020155
ADMINISTRATOR/
DIRECTOR:		MAILE JUAREZFACILITY TYPE:
850
ADDRESS:1135 GAVIOTA AVETELEPHONE:
(310) 924-7515
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY: 77TOTAL ENROLLED CHILDREN: 61CENSUS: 36DATE:
04/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Maile JuaresTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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While conducting an investigation for a complaint, Licensing Program Analysts (LPAs), T. Tran and P. Bowden observed the following deficiency:

During the interviews and record reviewed, facility failed to report the incidents occurred on 12/04/23 and 4/7/23 both incidents required medical attention.

LPAs obtained the complete LIC 624 reports for the incidents occurred on 12/4/23 and 4/7/23 along with the Declaration Statement form the facility representative during today's visit. Plan of Correction was cleared during today's visit.

Facility was cited a type B deficiency. See Facility Evaluation Report LIC 809D for deficiency cited.

Deficiency was cited at this time. A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with the facility representative, Maile Juarez.
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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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Document Has Been Signed on 04/05/2024 02:58 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 04/05/2024 at 02:35 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: MUSE ACADEMY INC., THE
FACILITY NUMBER: 198020155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited
CCR
101212

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Reporting Requirements
This requirement is not met as evidenced by based on record review facility failed to report the incidents occurred on 12/4/23 and 4/7/23 which poses a potential health and safety risk to children in care.
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During today's visit, facilty representative completed LIC 624 reports for the incidents occurred on 12/4/23 and 4/7/23 along with the Declaration Statement form.
Plan of Correction was cleared during today's visit.

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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:Denise Gibbs
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024


LIC809 (FAS) - (06/04)
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