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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 10/27/2022
Date Signed: 10/27/2022 10:06:34 AM


Document Has Been Signed on 10/27/2022 10:06 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ACC MAPLE TREE VILLAGEFACILITY NUMBER:
342700683
ADMINISTRATOR:BRENDA CHAPPELLFACILITY TYPE:
740
ADDRESS:18 KADO CTTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 63DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Brenda ChappellTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 10/27/2022 at 9:45am. LPA met with Brenda Chappell, Administrator and stated the purpose of the visit.

LPA inquired if staff #1 (S1) was presently on the premises during this visit. Administrator Brenda Chappell stated the staff does not work in the facility any longer. S1 last worked in the facility on 5/5/2022.

LPA served notice of "ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY" for S1 who was not present at the time of visit. Administrator was advised an immediate removal is warranted and requested the Personnel Report (LIC500) and Guardian account be updated to remove S1 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL).

LPA informed Administrator that S1 is not allowed to be employed and/or on any facility premises. The Order to Individual of Immediate Exclusion From All Facilities came into effect as of 10/27/2022 upon receipt of the letter. A copy of the letter was given to the facility during this visit.

The facility understands this is an Immediate Exclusion and has agreed S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held, A Copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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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