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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 01/12/2023
Date Signed: 01/13/2023 12:35:13 PM

Substantiated


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
10/11/2022 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20221011154411
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: 67DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
03:54 PM
MET WITH:Yesenia JonesTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
2. Untrained staff are administering medications to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
THIS REPORT AMENDS THE VERBIAGE FOR ALLEGATION #2 WHICH CONTINUES TO REMAIN SUBSTANTIATED AND THE FINDINGS FOR ALLEGATION(S) 7 AND 8 TO BE CHANGED TO UNFOUNDED. ADMINISTRATOR AGREED.

Regarding allegation, "Staff are not following physician's instructions when administering medications to residents in care." Licensing Program Analyst observed an incident report submitted to Community Care Licensing that indicated that there was a medication error. Resident 1 had a medication discontinued by the doctor on 7/14/22 but staff continued to administer the medication to the resident for 4 months and 4 days which ended on 10/5/22. There were no adverse effects to resident 1.

This allegation continues to be Substantiated which was cited 1/4/2023 and Plan of Correction was cleared.
Substantiated
Estimated Days of Completion: 60
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 2
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
10/11/2022 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20221011154411

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: 67DATE:
01/12/2023
UNANNOUNCEDTIME BEGAN:
03:54 PM
MET WITH:Yesenia JonesTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
7. Staff are not reappraising residents in care as required.
8. Staff are not maintaining accurate care needs records regarding residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Regarding allegation, "Staff are not reappraising residents in care as required." Staff 1 and Staff 2 both concur that the assessments were only done for the assisted living side and not the memory care side. However, upon further review of documentation, LPA observed that appraisals were conducted as the facility changed the naming convention of their records to read Resident Functional Evaluation.
Regarding allegation, "Staff are not maintaining accurate care needs records regarding residents in care. “Staff 5 stated that the facility is behind on updating the resident records except for those who have a change in condition. However, upon further review of documentation, LPA observed that resident records had been updated prior to the Department receiving this complaint. The investigation revealed that based on interviews and documentation, the preponderance of evidence standards has not been met.
“This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.” Per CCR, Title 22, Division 6, Chapter 8, no violations were cited during this visit. An exit interview was conducted, and a copy of this report was provided.
Unfounded
Estimated Days of Completion: 60
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2