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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209069
Report Date: 08/09/2024
Date Signed: 08/09/2024 06:14:34 PM


Document Has Been Signed on 08/09/2024 06:14 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
FRESNO RO, 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: 4DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee, Irina ChernyakovaTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sarah Hurt, and Martin Vega conducted an unannounced visit today for the facility’s annual inspection. LPA's met with Licensee, Irina Chernyakova, Continual Administrator's Certification expires 01/03/2025. There are currently 4 residents who reside at this home and there is 2 residents on hospice at this time. LPA's inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Smoke alarms were tested and are operational. The home has a carbon monoxide detector. Water temperature was tested at 113 degrees Fahrenheit.

LPA’s observed facility fire extinguisher has not been serviced within one year. Fire extinguisher last serviced June 2023. LPA’s observed Resident 1 did not have a prescription for as needed sleep medication being administered. The facility is not performing disaster drills as required.

LPA’s observed molding, and rotten vegetables inside facility refrigerator. LPA’s observed several cans of expired food stored in area used as pantry. LPA’s observed a can of Lysol kept near food inside pantry area. LPA’s observed several toxins, and chemicals including without proper labels accessible to residents. LPA’s observed Resident 1’s Physician report not updated annually as required and does not have Tuberculosis test. Facility residents do not have Pre- Admission Assessments or Needs and Services plans. LPA’s observed facility staff removes medications from original container, and places in weekly pill organizer one week prior to administering to resident.

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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 14


Document Has Been Signed on 08/09/2024 06:14 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAPLE TREE CARE HOME 2
FACILITY NUMBER: 107209069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(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, LPAs observed fire extinguisher last serveiced on 06/2023, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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licensee will have fire extinguisher serviced and provide proof to LPA by 8/23/24 POC date
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on, observation and record review, the licensee did not comply with the section cited above, LPAs during record review observed that staff 1 did not have TB test included on Health Screening Report, however was not associated with facility. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee will ensure Staff has correct health screening, and send proof to LPA by POC 8/23/24.
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: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 14


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MAPLE TREE CARE HOME 2
FACILITY NUMBER: 107209069
VISIT DATE: 08/09/2024
NARRATIVE
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Staff 1 is fingerprint cleared, but not associated to this facility.

Staff 2 does not have completed Health Screening Record (no TB test)

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Irina Chernyakova, and copy of report left at facility

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 10 of 14
Document Has Been Signed on 08/09/2024 06:14 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAPLE TREE CARE HOME 2
FACILITY NUMBER: 107209069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)

87309(a)
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by: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 in LPAs observed in facility resident restroom, and laundry room, chemical containers unlocked, and accessible to residents. LPAs also observed chemicals not in their original container and placed in food containers, which poses an immediate health, safety or personal rights risk to persons in car
POC Due Date: 08/10/2024
Plan of Correction
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Licensee will provide training to staff on proper storage and handling of cleaning solutions, and send proof to LPA by POC date of 08/10/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 11 of 14


Document Has Been Signed on 08/09/2024 06:14 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAPLE TREE CARE HOME 2
FACILITY NUMBER: 107209069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication.(2) The exact dosage.(3) The minimum number of hours between doses.(4) The maximum number of doses allowed in each 24-hour period.
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 in Resident 1 does not written prescription for PRN sleeping medication, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee will provide written prescription for Residents PRN sleeping medication, and provide proof to LPA's by POC date of 08/23/2024.
Type B
Section Cited
CCR
87705(a)(5)
87705 Care of Persons with Dementia


(a) This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia. Mild cognitive impairment, as defined in Section 87101(m), is not considered to be dementia.(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Resident 1 did not required have annually updated Physician's report. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee will update Resident 1's Physician's report, and send proof to LPA's by POC date of 08/23/2024.
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: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 12 of 14


Document Has Been Signed on 08/09/2024 06:14 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MAPLE TREE CARE HOME 2
FACILITY NUMBER: 107209069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above, Resident 1 did not have requeired TB test, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licesee will submit R1 TB record to LPA by POC date of 8/23/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 14 of 14