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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209069
Report Date: 08/21/2020
Date Signed: 08/21/2020 11:11:10 AM

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 2FACILITY NUMBER:
107209069
ADMINISTRATOR:CHERNYAKOVA, IRINAFACILITY TYPE:
740
ADDRESS:2081 E RYAN LANETELEPHONE:
(559) 916-5206
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 0DATE:
08/21/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Irina ChernyakovaTIME COMPLETED:
11:30 AM
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On 08/21/2020, Licensing Program Analyst (LPA), A. Walton conducted a Tele-visit with Administrator, Irina Chernyakova via FaceTime due to COVID-19 and precautionary measures. LPA introduced self and stated the purpose of the call. The purpose of today's visit is to commence a Pre-Licensing / Componet III inspection.

The facility is a 6 bedroom and 3 bathroom home. Fire clearance was granted for 5 Non-Ambulatory, and 1 Bedridden for a total capacity of 6. There are no residents present during the inspection.

LPA toured the facility via FaceTime with Administrator. The facility tour began in the kitchen. LPA observed dishes, plates, and utensils. Knives were observed to be locked in a drawer near the refrigerator. The tour continued to the hallway, laundry room, and garage. LPA observed an extra supply of linens and towels. Cleaning supplies observed to be locked in a cabinet above the washing machine/dryer. Facility has a tankless water heater that instantly heats water as it flows through the device. Water heater was set at 120 degrees F for the facility. In the garage, LPA observed an emergency supply of food and water.

Facility tour continued to resident bedrooms and bathrooms. Bedrooms were equipped with required furnishings and are ready for occupancy. Resident bedrooms have an sliding glass door used for exiting. Sliding glass doors were equipped with a delayed egress device that will alert staff if resident exits through the door. Bathrooms were observed to be equipped with grab bars and non-skid mats.

Continued to LIC809-C
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020
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 2
FACILITY NUMBER: 107209069
VISIT DATE: 08/21/2020
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Resident medications will be kept locked and inaccessible in a cabinet in the hallway above the staff work area. Smoke Detector and Carbon Monoxide were observed to be operational during the inspection. A fire extinguisher was observed and had a service date of 7/20/2020. First-Aid kit was observed and contained all required items.

Administrator and LPA toured the outside of the facility. Exits were open and free from obstructions.

Component III was conducted during today's pre-licensing visit.

I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020
LIC809 (FAS) - (06/04)
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