107209069-2-24-2021-24-AS-MHON-BZ2NZK-20210312095427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107209069
Report Date: 02/24/2021
Date Signed: 02/24/2021 11:11:09 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/24/2020 and conducted by Evaluator Alexandria Walton

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20201224132311

FACILITY NAME:	MAPLE TREE CARE HOME 2		FACILITY NUMBER:	107209069
ADMINISTRATOR:	CHERNYAKOVA, IRINA		FACILITY TYPE:	740
ADDRESS:	2081 E RYAN LANE		TELEPHONE:	(559) 916-5206
CITY:	FRESNO	STATE: CA	ZIP CODE:	93720
CAPACITY:	6	CENSUS: 1	DATE:	02/24/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Irina Chernyakova		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Staff physically abused resident
Staff verbally abused resident
Staff failed to meet the resident's needs

INVESTIGATION FINDINGS:

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On 2/24/2021, Licensing Program Analyst (LPA) A. Walton contacted Administrator, Irina Chernyakova to deliver findings on the above allegations via telephone due to COVID-19 and precautionary measures. LPA introduced self and discussed the purpose of the call with Administrator.

The Department investigated the above allegations and based on interviews and records review, there is not a preponderance of evidence to prove or disprove that the allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies issued. An exit interview was conducted with Adminsitrator. A copy of this report was discussed and provided via email and an electronic read receipt confirms receiving these documents

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

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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