<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 10/10/2023
Date Signed: 10/10/2023 04:36:16 PM


Document Has Been Signed on 10/10/2023 04:36 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:YESENIA JONESFACILITY TYPE:
740
ADDRESS:18 KADO CTTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 87DATE:
10/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Yesenia JonesTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) arrived unannounced on 10/10/23 at 1:30p to obtain additional information regarding an SIR received 2/2/23. LPA met with Yesenia Jones, Administrator and stated the purpose of the visit.

LPA reviewed with administrator the contents of the SIR.

The administrator conducted an internal investigation where as the care staff was providing medication administration timely and resident was not refusing to take medication.

Resident #1, was not experiencing adverse reaction, however, it was noted that R1 was actually not swallowing the medication and was discarding them once staff was not present (cheeking). The responsible parties found the medications in R1's clothing.

Based on the information provided, this has not occurred before and precautions have been put into place to assist staff in ensuring medications are taken by residents or document any refusals. The facility conducted in-service to medication technicians to try to ensure residents are swallowing medications before leaving the area.

The facility was deemed to not be at fault for medication error at this time.

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: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1