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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197419436
Report Date: 04/17/2023
Date Signed: 04/17/2023 11:32:59 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/23/2023 and conducted by Evaluator Doris Whitmore
PUBLIC
COMPLAINT CONTROL NUMBER: 58-CC-20230123122539
FACILITY NAME:LITTLE TREEHOUSE ACADEMYFACILITY NUMBER:
197419436
ADMINISTRATOR:ANNA SHIROKOVAFACILITY TYPE:
830
ADDRESS:18510 PLUMMER STREETTELEPHONE:
(818) 772-9320
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:18CENSUS: 4DATE:
04/17/2023
ANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Anne ShirokovaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Reporting Requirements
Personal Rights
INVESTIGATION FINDINGS:
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On 01/26/2023 Licensing Program Analyst Doris Whitmore met with Anna Shirokova Director, LPA observed a total of one teacher and two infants. LPA toured the facility indoors and outdoors, observing proper teacher/child ratios with 2 infants in care. LPA obtained the following documents Personnel Report, Safe Feeding Practices to Prevent Choking handout, First Aid& CPR Certificates, Mandated Reporter General Training Certificate, Illness Form. Employee Development on Supervision & Staff in Service Training, Parent Consent for administration of medication & other documentation pertaining to this investigation. The Department conducted a full investigation which included interviews with Staff and relevant parties. Based on interviews facility did notify child’s authorized representative of incident in a timely manner. Staff did not seek emergency medical attention for day care child. Therefore, the allegations of Reporting Requirements and Personal Rights is substantiated, meaning that the allegation is valid because the preponderance of the evidence standards has been met.Documents that were given to Anna Shirokova was the LIC 9224 Type A Deficiency, license shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/ guardians of children in care and enrolled at the facility by the close of business the following day or the next day.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 58-CC-20230123122539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: LITTLE TREEHOUSE ACADEMY
FACILITY NUMBER: 197419436
VISIT DATE: 04/17/2023
NARRATIVE
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The same report must be provided to parents or guardians of children newly enrolled at the facility during the next 12 months & licensee will obtain a signed Acknowledgement of Licensing Reports (LIC9224) from parent/ guardian and place it in each child's file.
Deficiency cited LIC9099D and a copy of this report issued Notice of Site Visit and Appeal Rights.


SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 58-CC-20230123122539
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: LITTLE TREEHOUSE ACADEMY
FACILITY NUMBER: 197419436
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2023
Section Cited
CCR
101226(a)(2)
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The license shall immediately notify the child's authorized representative if the child becomes ill or sustain an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from tthe authorized representative regarding action to be taken. The licensee shall immediately notify the child's authorized representative if the child becomes ill or substains an injury more serious than a minor cut or scratch. The license shall obtain specific instructions from the authorized representative regarding action to be taken.This requirement is not met as
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The Department will schedule a Supervisory Conference to further speak with Licensee to ensure that this type of incident does not occur in the future.
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evidenced by: On 01/19/23 Child was choking, and the facility did not provide immediate full disclosure of the seriousness of the medical incident to the child's parent
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Type A
04/20/2023
Section Cited
CCR
101223(2)(2)
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The licensee shall ensure that each child is accorded the following personal rights, to be accorded safe, healthful and comfortable accommodations, furnishings, and equipment to meet his/her needs. This requirement is not met as evidenced by: On 01/ 19/23 child's breathing was impaired, and facility did not contact medical personnel even though a form of first aid was rendered by staff.
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Licensee will provide written declaration on how to properly assess injuries and immediately seek medical attention for injuries needing medical attention by 04/20/2023
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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.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3