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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 10/23/2025
Date Signed: 10/23/2025 03:35:54 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20250218132220
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: 93DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Yesenia JonesTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
1) Staff did not ensure residents personal items were safely secured
2) Staff damaged residents personal property
3) Staff do not ensure residents are spoken to in an appropriate manner
4) Staff do not ensure resident receives assistance with dental hygiene

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the ACC Maple Tree Village RCFE on 10/23/25 at 9:20am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Administrator, Yesenia Jones and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA Gould condeucted interview with R1 who was alert orienatded and able to respond to LPA questions. Per interview R1 denied needing assistance with dental hygiene. Per R1's needs and services plan, R1 did not have full assist with dental hygiene, R1 was listed as needing prompting and setting up toothbrush and toothpaste and R1 was documetned as able to complete this ADL. R1 denied the allegation of being spoken to in an inappropriate manner. R1 only provided positive statemets regarding staff interactions and identified as being treated with kindness and respect. Report Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20250218132220

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: 93DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Yesenia JonesTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Other: Staff do not respond to residents call buttons in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the ACC Maple Tree Village RCFE on 10/23/25 at 9:20pm to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator, Yesenia Jones and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. the department obtained and reviewed call log response times for R1. LPA and the department observed several instances where the response time exceeded facility and department expectations. Some of the intances were explained by staff members not resetting the call pendant but other identified delays could not be identified by the facility administrator.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Other is substantiated. Report Contined on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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 5
Control Number 27-AS-20250218132220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ACC MAPLE TREE VILLAGE
FACILITY NUMBER: 342700683
VISIT DATE: 10/23/2025
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
26
27
28
29
30
31
32
The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250218132220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ACC MAPLE TREE VILLAGE
FACILITY NUMBER: 342700683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2025
Section Cited
CCR
87464(f)
1
2
3
4
5
6
7
Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by observed delays in responses to pressed resident pendant which poses a potential
1
2
3
4
5
6
7
Facility has agreed to conduct weekly audits for one month and provide those audits to the department each Friday. Any delays will be identified and provide information as to what steps the facility has taken in regards to each individual incident.
8
9
10
11
12
13
14
health, safety and personal right srisk 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250218132220
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ACC MAPLE TREE VILLAGE
FACILITY NUMBER: 342700683
VISIT DATE: 10/23/2025
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
26
27
28
29
30
31
32
Regarding allegations that personal items were not secured. LPA conducted a review of R1's documented inventory and observed the inventory was declined at admission and was never updated with any items of personal value documented including perfume. LPA reviewed the Theft/Loss policy binder and observed the perfume to be documented appropriately per Title 22 regulations. As no items have been documented as part of the resident inventory, LPA was unable to obtain any evidence the item as described was present at the facility prior to being reported missing to the administrator. Additionally, R1 denied any clothing items were damaged by ACC staff. LPA and R1 looked at a few clothing items and LPA only observed R1's name documented in tags and on interior clothing identifying R1's clothing.

Staff interviewed denied making any statements or remarks to any residents
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5