107206761-8-11-2024-24-AS-BCHN-D8DTV9-20240822150334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206761
Report Date: 07/18/2024
Date Signed: 08/11/2024 11:12:02 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
04/09/2024 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240409143113

FACILITY NAME:	MAPLE TREE CARE HOME		FACILITY NUMBER:	107206761
ADMINISTRATOR:	CHERNYAKOVA, IRINA		FACILITY TYPE:	740
ADDRESS:	2103 E. RYAN AVENUE		TELEPHONE:	(559) 434-7371
CITY:	FRESNO	STATE: CA	ZIP CODE:	93720
CAPACITY:	6	CENSUS: 5	DATE:	07/18/2024
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Administrator Irina Chernyakova		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.
Staff yelled at resident.
Staff did not follow resident's modified diet.

INVESTIGATION FINDINGS:

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On 07/18/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Irina Chernyakova and stated the purpose of the visit.
During this visit LPA toured the facility inside and out and observed residents in care.

Allegation: Staff handled resident in a rough manner. Based on interviews, observations, no residents reported being handled in rough manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
Allegation: Staff yelled at resident. Based on observations, interviews no guest or residents observed staff yell at resident. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Report continues on attached LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20240409143113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAPLE TREE CARE HOME	FACILITY NUMBER: 107206761
	VISIT DATE: 07/18/2024

NARRATIVE

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Allegation: Staff did not follow resident's modified diet. Based of interviews and records review the facility followed residents diet. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted, report signed and copy of this report provided to Administrator for facility records.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

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