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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206761
Report Date: 10/29/2021
Date Signed: 11/02/2021 11:34:18 AM

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: 5DATE:
10/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:26 PM
MET WITH:Licensee, Irina ChernyakovaTIME COMPLETED:
05:30 PM
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On 10/29/2021 Licensing Program Analyst (LPA) M. Garza arrived at facility and met with Licensee, Irina Chernyakova.

LPA met with Licensee to return R1’s file. File was removed from facility on 10/29/2021 in order to make copies. Copies were made for the complaint allegations and returned same day.

A copy of this report will be emailed due to COVID precautionary measures. A delivered and read receipt will be sent as confirmation.

Email: mapletreecarehome@yahoo.com

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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