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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 11/08/2022
Date Signed: 11/08/2022 03:11:48 PM


Document Has Been Signed on 11/08/2022 03:11 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, 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: 64DATE:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Stacy Sharp, Resident Care ManagerTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/8/22 at 10am to conclude an investigation regarding a Special Incident Report (LIC624) that was submitted to the Department on 9/28/2021 that indicated there was a medication error on 9/19/2021. LPA was met by Dominique Matsuhiro-Cea, Office Coordinator and Stacy Sharp, Resident Care Manager and stated the purpose of the visit. This is a continuation report from the Community Care Licensing (CCL) visit conducted on 5/16/22.

LPA reviewed documents for Resident#1 (R1-R2) such as print outs from PointClickCare system dated 5/17/22.
In addition, LPA was furnished with a facility laptop to review resident records on the PointClickCare system during this visit.

This investigation revealed that Resident #1 (R1) was missing medication (Hydrocodone w/Acetaminophen) because it was mistakenly administered to R2.

LPA also observed a copy of a hand-written document that staff was provided an in-service training regarding medication errors on 9/19/21. In addition, LPA received information that the staff involved is no longer working for the facility.

Based on documentation review, the preponderance of evidence has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Resident Care Manager was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided during this visit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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Document Has Been Signed on 11/08/2022 03:11 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, 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: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2022
Section Cited

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Incidental Medical and Dental Care
In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring ... assisting residents as needed with self-administration of medications...
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This requirement is not met as evidenced by: medication that belonged to R1 was administered to R2 and there was no adverse reaction
Based on documentation which confirmed the medication error occurred
This violation poses an potential 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: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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