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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100403618
Report Date: 11/07/2022
Date Signed: 11/07/2022 02:14:17 PM


Document Has Been Signed on 11/07/2022 02:14 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MAPLE AVENUE GUEST HOMEFACILITY NUMBER:
100403618
ADMINISTRATOR:ARCUINO, ELDADFACILITY TYPE:
740
ADDRESS:3341 NORTH MAPLE AVENUETELEPHONE:
(559) 227-9722
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY:14CENSUS: 13DATE:
11/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Camalah KopaczTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived at the the facility unannounced to conduct a Case Management related to observations of violations during a complaint investigation visit on 7/22/2022. LPA met with Camalah Kopacz and explained the purpose of the visit.

During a facility visit on 7/22/2022, LPA Brown made the following observations:
1. Storage Space:
Accessible cleaning products under the bathroom counter
Multiple disposable razors placed on top of a paper towel dispenser in resident bathroom

2. Maintenance and Operation:
A piece of cardboard covering a broken windowpane (kitchen window).
Dirty resident bedroom floors, baseboards and windowsills, walls, light-switch covers, shower floors
Pile of baskets and trash at the top of the stairs into staff room
Broken bedroom furniture in resident rooms - Night stands and dressers missing drawers
Broken hanging blinds

3. Personal Accommodations and Services:
Multiple resident beds with soiled sheets and missing required bedding
Multiple resident rooms smell of urine

4. Fire Safety:
A dresser blocking an Emergency Exit in a resident room to keep a resident from leaving the facility

See LIC809-C for continuation of this report
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 11/07/2022 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAPLE AVENUE GUEST HOME
FACILITY NUMBER: 100403618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement was not met as evidenced by:
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Licensee did not ensure that chemicals/cleaning supplies and items which could pose a danger to resident if readily available were locked and properly stored. LPA observed 3 disposable razors and unlocked cleaning supplies stored accessable being stored in resident bathroom.
This poses an immediate health, safety or personal rights risk to reisdents in care.
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Type B
11/21/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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Licensee did not ensure the facility is clean, safe, sanitary and in good repair. LPA observed a broken window pane, dirty bedroom floors, baseboards and windowsills, walls, broken bedroom furniture with missing drawers and broken blinds in resident rooms.
This poses a potential health, safety or personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/07/2022 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAPLE AVENUE GUEST HOME
FACILITY NUMBER: 100403618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited

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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function….(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident…(C) Clean linen, including blankets, bedspreads, top bed sheets,bottom bed sheets,
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pillow cases, mattress pads…. to ensure that clean linen is in use by residents at all times….
This requirement was not met as evidenced by:
LPA observed multiple residents beds with soiled or missing required linens. Multiple resident rooms smelled of urine.
This poses a health, safety or personal rights risk to residents in care.
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Type B
11/21/2022
Section Cited

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement was not met as evidenced by:
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Licensee did not maintain in conformity with the regulations adopted by the State Fire Marshal. LPA observed a dresser placed blocking an Emergency Exit door which staff stated was placed to keep resident from leaving through the door.
This poses a health, safety or personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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