107206761-6-29-2022-24-AS-AWAN-CFUPJE-20220629112125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206761
Report Date: 06/29/2022
Date Signed: 06/29/2022 11:21:35 AM

Document Has Been Signed on 06/29/2022 11:21 AM - It Cannot Be Edited

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 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: 3	DATE:	06/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Administrator, Irina Chernyakova		TIME COMPLETED:	11:32 AM

NARRATIVE

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On 06/29/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator (ADM), Irina Chernyakova. Facility has one central entry and exit. Facility has implemented a sign-in policy for visitors.

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 were not observed wearing facial coverings. LPA toured the facility kitchen. LPA observed a knife on the kitchen counter accessible to residents in care. LPA observed a 7-day supply of non-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. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs observed in resident bathrooms. LPA observed disinfectant wipes accessible to residents in care in 3 out of 3 bathrooms. LPA observed cleaning supplies/solutions, accessible to residents in care under the sink in bathrooms 1 and 2. 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.

Based on observation, a deficiency is being cited in accordance with to California Code of Regulations, Title 22, Division 6.

CONTINUED TO 809C

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAPLE TREE CARE HOME	FACILITY NUMBER: 107206761
	VISIT DATE: 06/29/2022

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LPA is requesting the following documents be submitted to the Fresno CCL office by 07/13/2022: Infection Control Plan, Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020) (LIC9020A) and Surety Bond.

Exit interview conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Irina Chernyakova, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/29/2022 11:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAPLE TREE CARE HOME	FACILITY NUMBER: 107206761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as evidenced by an accessible knife on the kithcen counter and disinfectants and cleaning solutions accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2022
	Plan of Correction
1 2 3 4	Licensee agrees submit a written statement detailing the steps the facility will take to ensure the above regulation is met by the POC due date. Licensee also agrees to keep the knives locked in a drawer in the kitchen and will install a lock on the cabinet in the bathrooms and submit proof of installation to the Fresno CCL office by 07/29/2022

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC809 (FAS) - (06/04)

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