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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206761
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:15:57 PM

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 TREE CARE HOMEFACILITY NUMBER:
107206761
ADMINISTRATOR:CHERNYAKOVA, IRINAFACILITY TYPE:
740
ADDRESS:2103 E. RYAN AVENUETELEPHONE:
(559) 434-7371
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 4DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Administrator, Irina ChernyakovaTIME COMPLETED:
02:55 PM
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On 06/23/2021, Licensing Program Analyst (LPA) Walton arrived unannounced at the above facility to conduct an Annual Inspection. Facility has one central entry and exit point. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Administrator (ADM), Irina Chernyakova. Upon entry, LPA observed a visitor log-in/temperature check.

Facility tour conducted with ADM. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA observed a 7-day supply of perishable foods and a 2-day supply of perishable foods. LPA observed a 30 day supply of PPE and cleaning supplies.

Residents at the above facility have private rooms. Bedrooms were stocked with hand sanitizer. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply. Resident temperature checks are documented daily. Resident records have updated emergency contact information. Facility staff records reviewed for good health and infection control training. Administrator certificate is current.

No deficiencies issued during this inspection.

Exit interview conducted. A copy of this report will be provided to ADM via email and an electronic read receipt confirms receiving this document. Administrator informed to select yes when prompted to send read receipt. Facility Representative signature on file.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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