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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206761
Report Date: 11/08/2021
Date Signed: 11/09/2021 06:51:47 AM



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
12/23/2020 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20201223135840
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:
11/08/2021
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Licensee, Irina ChernyakovaTIME COMPLETED:
01:23 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not follow admission agreement.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/8/2021 Licenisng Program Analyst (LPA) M. Garza arrived at facility to deliver findings on the above allegation. LPA met with Licensee, Irina Chernyakova and explained reason for visit. LPA completed a Health and Safety check on residents in care.

The Department has investigated the above allegation. Based on the interviews conducted and/or records reviewed, the above allegation is UNFOUNDED. Residents sign an Admission Agreement at the time of move in. The Adminission Agreement states that there is a $500 admission fee for administrative services provided that is non-refundable. Resident's are refunded any monies due to them. R1 was refunded the prorated fees not used.This agency has investigated the allegation and has found that the complaint is UNFOUNDED. This means that the allegation is false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. No deficiencies cited at this visit. Exit interview completed.

Due to COVID precautionary measures a copy of this report will be emailed. A delivered and read receipt serves as confirmation.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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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