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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209069
Report Date: 07/18/2022
Date Signed: 07/18/2022 11:51:03 AM


Document Has Been Signed on 07/18/2022 11:51 AM - It Cannot Be Edited

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: 3DATE:
07/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Caregiver, Mark CaluagTIME COMPLETED:
12:07 PM
NARRATIVE
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On 07/18/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Irina Chernyakova via telephone. Administrator is unable to attend today's inspection. LPA received verbal permission to meet with Caregiver, Mark Caluag.

Facility tour conducted with Caregiver. LPA observed the fire exits blocked by furniture in rooms 3 and 6. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA did not observe 7-day supply of non-perishable foods or a 2-day supply of perishable foods. LPA observed an adequate supply of PPE and cleaning supplies.

Residents at the above facility have private rooms. Bedrooms were stocked with hand sanitizer. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply.

LPA will return at a later date to review resident and staff records.

Deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D.

An exit interview was conducted with Caregiver and a Plan of Correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Caregiver.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 07/18/2022 11:51 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when the fire exits in rooms 3 and 6 were blocked by furniture which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2022
Plan of Correction
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Licensee agrees to remove the furniture from blocking the fire exits by the POC due date and submit proof to the Fresno CCL office.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/18/2022 11:51 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as evidenced by the facility not having a week supply of non-perishable foods and 2 day supply of perishable foods in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Licensee agreed to purchase the required amount of food items and will submit a written statement detailing the steps the facility will take to ensure the requirements for section 87555 are met to the Fresno CCL office by the POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3