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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 09/22/2021
Date Signed: 09/22/2021 12:01:38 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2021 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20210311145752
FACILITY NAME:ACC MAPLE TREE VILLAGEFACILITY NUMBER:
342700683
ADMINISTRATOR:DEBORAH KANIAFACILITY TYPE:
740
ADDRESS:7579 MAPLE TREE WAYTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 49DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Harumi Hurrianko, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Licensee did not ensure sufficient staffing
Licensee did not ensure resident's needs are met
No qualified Administrator available
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/22/21 at 10:00AM to conclude the investigation of the above-mentioned allegations. LPA met with Harumi Hurrianko, Administrator and discussed the purpose of the visit.

LPA received a copy of the roster of staff with contact information, a copy of the staff work schedule for the week of 2/21/21-3/6/2021 to include call offs, a copy of the LIC500 that includes work schedules for administrators, a copy of PRNs for all residents, a copy of any disciplinary actions and/or dismissals of staff for February and March, documented trainings for staff regarding emergencies, and roster of residents residing in the facility.
Regarding allegation, “Licensee did not ensure sufficient staffing”, LPA reviewed the Bi-weekly Staff Work Schedule. In reviewing the documents submitted, the schedule revealed staff who worked during the dates of 1/30/21 to 3/12/21. LPA also observed documentation that there were 4 resignations and 4 terminations between dates of 1/1/2021 to 3/12/2021.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20210311145752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ACC MAPLE TREE VILLAGE
FACILITY NUMBER: 342700683
VISIT DATE: 09/22/2021
NARRATIVE
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On a normal day, there would be 2 caregivers and a medication technician (MT) on each, the memory care side and the assisted living side of the building. LPA received information during interviews of staff that due to a shortage of staff, they were forced sometimes to work consecutive eight hour shifts for AM, PM, and Night (NOC). Although, the facility was using a staffing agency, the schedule showed that on several days, there was insufficient staffing. The staffing agency was not being utilized on the days when there were 1 or 2 caregivers on shift without a Medication Technician. Allegation deemed SUBSTANTIATED

Regarding allegation, “Licensee did not ensure residents needs are met” LPA observed on the staff biweekly work schedule, that on several days there were 1 or 2 caregivers without a MT. In addition, the 2 caregivers were separated with 1 caregiver for the memory care unit and 1 for the assisted living area. During interviews 3 employees confirmed that the residents were not assisted with a 2-person assist when there was a shortage of staff. The staff stated that when there was 1 caregiver the MT would assist with the 2 persons assist until it was time for medication passes. During the time of medication pass the residents could not be assisted. Allegation deemed SUBSTANTIATED

Regarding allegation, “No qualified Administrator available”, LPA obtained information during interviews of 3 employees who verified that the previous two Administrator(s) was unable to be reached when staff attempted to contact them during night (NOC) shift between the dates of 10/2/2020 and 3/26/21. Allegation deemed SUBSTANTIATED

Based on observation, interviews, and documentation the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20210311145752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ACC MAPLE TREE VILLAGE
FACILITY NUMBER: 342700683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2021
Section Cited
CCR
87411(a)
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Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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The Administrator shall submit a plan on how this will not occur in the future along with a current LIC500 by POC due date.
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This requirement is not met as evidenced by: Staff were forced to work extra shifts to assist the residents with care and supervision and staffing agency was not used on those days.
Based on documentation and interviews the facility failed to ensure staffing was sufficient in numbers for resident care and supervision
This violation poses an immediate health, and safety risk to residents in care.
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Type A
09/23/2021
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The Administrator shall submit a list of those residents needeing a 2-person assist according to their care plan. This information shall be notated as duties in training provided to staff. Training documentation is to be submitted by POC due date of 9/30/21.
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This requirement is not met as evidenced by: the residents who required a 2-person assist was not assisted due to a staffing shortage
Based on interviews, staff confirmed sometimes the residents were not assisted when there was not enough staff, or the MT needed to pass medications
This violation poses an immediate health, and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210311145752
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ACC MAPLE TREE VILLAGE
FACILITY NUMBER: 342700683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2021
Section Cited
CCR
87405(a)
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Administrator - Qualifications and Duties
All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
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The administrator shall include the administrator days and hours of presence in the facility on the LIC500 and a copy of LIC308 Designations forms for those in charge in the absence of the Administrator.
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This requirement is not met as evidenced by: Administrator(s) were not reachable during NOC shift
Based on interviews of staff who confirmed the previous administrators did not ensure coverage while not present in the facility during the NOC shift
This violation poses an immediate health, and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4