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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209069
Report Date: 07/12/2021
Date Signed: 07/12/2021 10:50:12 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:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:TIME COMPLETED:
10:50 AM
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On 07/12/2021, Licensing Program Analyst (LPA) arrived unannounced to conduct an Annual Inspection. LPA introduced self, disclosed the purpose of the visit and met with Administrator (ADM), Irina Chernyakova. Facility has one central entry and exit point. Visitor log-in observed.

There are currently no residents residing in the facility and there are no staff present. Per ADM, the facility is closed.

Facility tour conducted with ADM. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting social distancing, cough/sneeze etiquette, and hand-washing. Hand-sanitizer is available for residents and visitors. LPA checked food supply, observed a 7-day supply of non-perishable foods. Facility has an adequate supply of cleaning supplies.

ADM certificate is current.

No deficiencies were observed. Exit interview was conducted. ADM was informed that as a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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