342700683-7-31-2023-27-AS-KHOS-CUAPXW-20230801114301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 07/31/2023
Date Signed: 07/31/2023 04:14:55 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
05/05/2023 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20230505150432

FACILITY NAME:	ACC MAPLE TREE VILLAGE		FACILITY NUMBER:	342700683
ADMINISTRATOR:	YESENIA JONES		FACILITY TYPE:	740
ADDRESS:	18 KADO CT		TELEPHONE:	(916) 395-7579
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	125	CENSUS: 80	DATE:	07/31/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Yesenia Jones		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility is retaliating against resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegation on 7/31/23 at 8am. LPA met with Yesenia Jones, Administrator and Khownou Sharma Resident Care Coordinator and stated the purpose of the visit. LPA conducted interviews of staff #1 (S1-S5) during this visit.

LPA reviewed Incident report (LIC624) dated 5/2/23 indicating resident #1 (R1) was possibly rough handled during transfer on 4/29/23. It is unclear at this time if anyone "rough handled" the resident. Regarding, allegation, "Facility is retaliating against resident", LPA reviewed the facilities Dementia Care Plan of Operation and Facility Program Description. In the Program Description, LPA observed "upon admission, every resident is given a copy of the Personal Rights (LIC613C) form". LPA also observed under the section of Discipline Policies Personal Rights, which indicates residents have the right to relatives and individuals of their choosing visit privately during reasonable hours and without prior notice provided that the rights of other residents are not infringed upon.

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230505150432

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: 07/31/2023

NARRATIVE

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LPA did not observe a policy regarding the use of Personal/Private Caregiver/Companions in these documents.

Based on interviews, the facility staff were instructed by management to ask the residents companions to leave the room while care was being provided. Although the facility was trying to uphold the dignity of the resident, the resident still had the right to have the companion present.

The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

A copy of their rights was provided (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.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230505150432

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: 07/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/04/2023 Section Cited CCR 87468.2(a)(21)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Licensee shall submit a letter stating that all resident rights will be upheld and all policies shall be in writing with updates provided to CCL. POC to be faxed by POC due date.
	8 9 10 11 12 13 14	To consent to have their relatives and other individuals of their choosing visit during reasonable hours, privately, and without prior notice. This requirement is not met as evidenced by: Based on facility did not ensure resident rights were upheld by dismissing companions from the room. This poses a potential risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC9099 (FAS) - (06/04)

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