100403618-7-12-2024-24-AS-SMOA-D7VJWC-20240806072430

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 100403618
Report Date: 07/12/2024
Date Signed: 07/12/2024 04:42:16 PM

Substantiated

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
02/09/2024 and conducted by Evaluator Kelly J. McClurg

COMPLAINT CONTROL NUMBER: 24-AS-20240209144355

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: 11	DATE:	07/12/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Assistant Administrator (AA) Camalah Kopacz		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not treat residents with dignity and respect

INVESTIGATION FINDINGS:

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A during a scheduled Office visit a Complaint visit was conducted. Licensing Program Manager (LPA) S. Moua & Licensing Program Analyst (LPA) K. McClurg met with Assistant Administrator Camalah Kopacz.

Records reviewed. It was confirmed that staff has yelled at & touched head of residents in a manner that is not in compliance with the personal rights of residents.

The Department has investigated the above allegation & determined it to be Substantiated.

Deficiency issued.

Continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

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
02/09/2024 and conducted by Evaluator Kelly J. McClurg

COMPLAINT CONTROL NUMBER: 24-AS-20240209144355

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:	DATE:	07/12/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Assistant Administrator (AA) Camalah Kopacz		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
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5
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7
8
9

Staff member physically abused residents
Staff member uses an object to hit residents

INVESTIGATION FINDINGS:

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The Department has investigated the above allegations & determined them to be Unsubstantiated.

Exit interviewed conducted with AA. Report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 24-AS-20240209144355

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/19/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal	1 2 3 4 5 6 7	Assistant Administrator has agreed to conduct training with all staff regarding resident rights, including de-escalation & redirection. Training to be conducted prior to due date. Documentation of training to be in
	8 9 10 11 12 13 14	relationships with staff, residents, and other persons. It was determined during investigation that staff has yelled at resident & that resident's head has been touched in manner comprimising personal rights.	8 9 10 11 12 13 14	compliance with Section 87412(c)(2) Personnel Records. Training documentation along with printed name, job title, & signatures of staff in attendance. Documentation to be submitted by due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kelly J. McClurg	TELEPHONE: (559) 246-0435
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3