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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494263
Report Date: 05/22/2024
Date Signed: 05/22/2024 03:44:58 PM

Document Has Been Signed on 05/22/2024 03:44 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-INFANTFACILITY NUMBER:
197494263
ADMINISTRATOR/
DIRECTOR:		BLANCA SANCHEZFACILITY TYPE:
830
ADDRESS:2920 S SEPULVEDA BLTELEPHONE:
(323) 999-6930
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY: 70TOTAL ENROLLED CHILDREN: 70CENSUS: 30DATE:
05/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Amy Mach, DirectorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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On 05/22/2024, Licensing Program Analyst (LPA) Judy Laureano conducted an unannounced Case Management – Incident inspection related to a self-reported Unusual Incident Report (UIR) submitted on 03/13/2024. Upon arrival, LPA met with Director Amy Mech, and explained the purpose of the visit. LPA observed 30 children in care, being supervised and care for by 9 staff members.

According to the UIR that took place on 3/12/2024, Teacher Tania was feeding a group of 4 infants in the kitchen. She finished feeding one and switched out with another infant, C2. Tania opened a spot for C2 and began to prepare C2's cereal. Tania took a bottle of formula that was next to the cereal and poured it into the cereal. The bottle was labeled with C1's name and date. C2 was fed C1's formula. Children did not have a reaction to the formula. Lead teacher and director were notified of the incident. Director proceeded to informed parents of the incident.

Director confirmed Teacher took full responsibility of incident dated 3/12/2024. LPA's interviews with staff and director confirmed that Teacher Tania fed C2 the wrong formula. Teacher is no longer employed at facility and her last day of employment was 3/14/2024.

During today’s inspection, LPA toured the facility both indoors and outdoors. LPA observed and inspected the kitchen and the storage and labeling of children’s formulas and bottles. Director confirmed that all staff has been retrained around feeding procedures ensuring that all bottles and all necessary food is labeled accordingly. Staff is also checking multiple times before feeding that all items used belong to the correct child.

Based on staff interviews and document review of Infant Services Plan and other relevant documentation, facility failed to follow the individual plan of C1 and C2. Per Title 22 Regulations and Health and Safety Codes, Deficiency was cited today (see LIC 809-D).

An exit interview was conducted. A copy of this report (LIC 809) and Notice of Site Visit were provided to Director Amy Mach, and must remain posted for 30 days.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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 12/03/2024 02:26 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/02/2024 10:30 AM


Created By: Judy Laureano On 05/22/2024 at 02:12 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-INFANT
FACILITY NUMBER: 197494263

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/22/2024
Section Cited
CCR
101427(c)

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101427 (c) Infant Care Food Services
(c) The infant shall be fed in accordance with the individual plan.
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Director confirmed that all staff has been retrained around feeding procedures. Director provided LPA a copy of what steps have been taken to ensure the incident is not repeated.
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This requirement was not met as evidence by teacher admitting to feeding C2 the wrong formula on 3/12/2024.
**This is an amended report**
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Director agrees to submit via email a statement of discussion points that were covered including who received training by 5/29/2024.

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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:Judy Laureano
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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