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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100403618
Report Date: 07/12/2024
Date Signed: 07/12/2024 01:14:08 PM


Document Has Been Signed on 07/12/2024 01:14 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: 11DATE:
07/12/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Assistant Administrator (AA) Camalah KopaczTIME COMPLETED:
01:00 PM
NARRATIVE
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An Informal Office Meeting was conducted on this date to discuss concerns at the facility. Present during the meeting were:

Licensing Program Manager, See Moua
Licensing Program Analyst, Kelly McClurg
Administrator, Camalah Kopacz

The following issues were discussed:
-The accessibility of chemicals and hazardous materials to residents at the facility.
-The personal rights of the residents because of inaccessibility to hygiene products (toilet paper, soap etc).
-Staffing at the facility.

Inspection tool was discussed for Annual visits.

During the course of the meeting, findings were delivered for Complaint #24-AS-20240209144355, received on 2/9/24.

Exit interview was conducted at the conclusion of the meeting.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurgTELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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