107206761-8-11-2024-24-AS-BCHN-D8DUJY-20240822153820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206761
Report Date: 07/18/2024
Date Signed: 08/11/2024 11:15:04 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
05/06/2024 and conducted by Evaluator Vadim Gorban

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240506123424

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: 5	DATE:	07/18/2024
		UNANNOUNCED	TIME BEGAN:	11:06 AM
MET WITH:	Administrator Irina Chernyakova		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent resident from having exposure to a hazardous substance.
Staff did not ensure that resident was fed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 07/18/2024, 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 did not prevent resident from having exposure to a hazardous substance. Based of interviews and observations no hazardous substances available to residents observed. 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.
Allegation: Staff did not ensure that resident was fed. Based on file review and observation during the facility visit on 5/08/24 no concerns observed. 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 Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim Gorban	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 1