100403618-11-7-2022-24-AS-SPIY-CL7VBS-20221115151802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 100403618
Report Date: 11/07/2022
Date Signed: 11/07/2022 02:12:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2022 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20220715163911

FACILITY NAME:	MAPLE AVENUE GUEST HOME		FACILITY NUMBER:	100403618
ADMINISTRATOR:	ARCUINO, ELDAD		FACILITY TYPE:	740
ADDRESS:	3341 NORTH MAPLE AVENUE		TELEPHONE:	(559) 227-9722
CITY:	FRESNO	STATE: CA	ZIP CODE:	93726
CAPACITY:	14	CENSUS: 13	DATE:	11/07/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Camalah Kopacz		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff spoke to resident in an inappropriate manner
Staff does not perform job duties

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to deliver the complaint investigation findings. LPA met with Administrator (AD) Camalah Kopacz and explained the purpose of the visit.

1. The Department investigated the allegation: Staff spoke to resident in an inappropriate manner. Multiple residents were interviewed. None of the residents who were interviewed stated that staff yell or speak inapparently. It was reported that some residents are resistive to assistance and staff may raise their voices to gain resident attention.

2. The Department investigated the allegation: Staff does not perform job duties. During an interview, the A described the staff job duties. Per AD, prior to admission individuals are assessed to determine that they are ambulatory and require minimal care. A record review was conducted. AD did not have a document which states the responsibilities and duties of the live-in staff members.
See LIC9099-C for continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20220715163911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/07/2022

NARRATIVE

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Based on interviews conducted and record review, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

No citations were issued for these allegations.

An exit interview was conducted, and a copy of this report was left with Camalah Kopacz, whose signature on this form confirm receipt of these documents

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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