<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209069
Report Date: 07/29/2022
Date Signed: 07/29/2022 12:58:10 PM


Document Has Been Signed on 07/29/2022 12:58 PM - 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: 5DATE:
07/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Administrator, Irina ChernyakovaTIME COMPLETED:
01:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/29/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a POC visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Irina Cherynakova.

On 07/18/2022, LPA conducted an annual inspection at the above facility. LPA issued a citation based on California Code of Regulations section 87202(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. Administrator agreed to remove the chairs blocking the fire exits in the residents rooms. Administrator was given a plan of correction date of 07/19/2022.

During today's inspection, LPA observed chairs blocking the exits in the residents apartment. Administrator removed the chairs that were blocking the emergency exits during today's visit. LPA also observed cameras in each resident bedroom. Per Administrator, the cameras are in the room to watch the residents at night.

Based on observation, a deficiency is being issued in accordance with California Code of Regulations, Title 22, Division 6, section 87468.2(a)(1). A civil penalty in the amount of $100 per day for 9 days is being assessed for failure to correct for a total amount of $900.

An exit interview was conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Irina Cherynakova, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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 2


Document Has Been Signed on 07/29/2022 12:58 PM - 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: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2022
Section Cited

1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1... (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on observation, Licensee did not ensure residents have a reasonable level of personal privacy as evidenced by cameras installed in 6 out of 6 resident bedrooms.
8
9
10
11
12
13
14
Licensee also agrees to remove the cameras in the resident bedrooms and submit proof of removal to the Fresno CCL office by 08/19/2022.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2