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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206761
Report Date: 05/08/2024
Date Signed: 05/08/2024 06:52:45 PM


Document Has Been Signed on 05/08/2024 06:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
107206761
ADMINISTRATOR:CHERNYAKOVA, IRINAFACILITY TYPE:
740
ADDRESS:2103 E. RYAN AVENUETELEPHONE:
(559) 434-7371
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 6DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:53 PM
MET WITH:Administrator, Irina ChernyakovaTIME COMPLETED:
04:44 PM
NARRATIVE
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On 05/08/2024, Licensing Program Analysts (LPAs) V Gorban and B Miranda unannounced visited facility stated above to commence complaint investigation and complete a residents safety check. During this visit LPA met with facility staff Irina and Mercy. Administrator (AD) was notified of Licensing visit and was able to attend it.

During the facility visit the facility staff shared with LPA that the fire department visited the facility on 4/14/2024 because of R1 call to FFD. When LPAs requested the incident report the Administrator did not have any reports on record to provide to Licensing.

Also, during the facility tour on 5/08/24 LPA observed residents bed full rails raised up restricting resident mobility in rooms, 1, 2, 5, and 6. Full raised bed rails medical order was not provided by Administrator when requested.


The deficiencies will follow on attached LIC809-D
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/08/2024 06:52 PM - 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAPLE TREE CARE HOME
FACILITY NUMBER: 107206761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements. (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified below. This was not observed as evidenced by:
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By plan of correction facility will ensure to review and follow title 22, reporting requirements and submit to LPA by email written statement by 05/10/24.
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Facility failed to submit incident report for R1 that occurred on 4/14/24 in timely manner to Licensing, which posses potential safety risk to residents in care.
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Type B
05/14/2024
Section Cited
CCR87608(a)5(b)

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87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This was not observed as evidenced by:
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The facility will provide requested files to Licensing department by POC due date (5/14/24) The facility will follow Licensing regulations and maintain residents bed rails as ordered by physician.
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The facility failed to follow regulation by acquiring required documents and without proper documentation have residents full rails raised. That poses potential health and safety risk to residents in care.
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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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2