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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206761
Report Date: 05/10/2024
Date Signed: 05/13/2024 08:31:22 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
05/09/2024 and conducted by Evaluator Vadim Gorban
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240509101316
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:
05/10/2024
UNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Administrator, Irina ChernyakovaTIME COMPLETED:
03:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff removed resident's bed rails without proper authorization
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/10/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Irina Chrnyakova and stated the purpose of the visit.
During this visit LPA toured the facility inside and out and observed residents in care.
Once the tour was complete, LPA discussed the findings with the AD.

Allegation: Staff removed resident's bed rails without proper authorization. Based of interviews and record reviews R1 does not have order to have rails or any other postural support on the bed. 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.

Exit interview conducted, report signed and copy of this report provided to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
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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