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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 06:54:38 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:
01:24 PM
MET WITH:Licensee, Irina ChernyakovaTIME COMPLETED:
02:08 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff unlawfully evicted resident while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/8/2021 Licensing 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 complaint alleging the above allegation. Based on the interviews conducted and/or records review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED

Exit interview was conducted.

Due to COVID precautionary measures a copy of this report will be emailed. A delivered and read receipt serves as confirmation.
Unsubstantiated
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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