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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100403618
Report Date: 01/09/2024
Date Signed: 01/09/2024 01:06:56 PM


Document Has Been Signed on 01/09/2024 01:06 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: 14DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:House Manger (HM) Edris "Cindy" KavanaghTIME COMPLETED:
01:00 PM
NARRATIVE
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An unannounced Annual visit was conducted on the date & time above. Licensing Program Analyst (LPA) K. Mcclurg met with House Manager (HM) Edris "Cindy" Kavanagh. LPA introduced self & stated purpose of visit. Acting Administrator (AD) Camalah Kopacz not available @ time of visit. LPA conducted visit with HM.


Facility toured. Physical plant reviewed with HM. Shed in backyard containing hazardous items such as paint unlocked. Lock placed on shed @ time of visit. Smoke detectors & carbon monoxide detectors throughout facility. Fire extinguisher service date: June 2023.

Facility will require physical plant follow-up & record review @ a different date.

Deficiency issued & cleared @ time of visit.

Exit interview done with HM. Copy of report to be provided.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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 2


Document Has Been Signed on 01/09/2024 01:06 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: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Backyard shed containing paint & miscellaneous items observed to not have a lock & accessible to clients.
POC Due Date: 01/09/2024
Plan of Correction
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Shed locked @ time of visit
DEFICIENCY CLEARED.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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