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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:26:11 PM


Document Has Been Signed on 04/16/2024 02:26 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: DATE:
04/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Yesenia JonesTIME COMPLETED:
03:00 PM
NARRATIVE
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On 4/16/24 at 12:15pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to address concerns regarding an incident report received by the department on 4/15/24. LPA met with administrator Yesenia Jones and together discussed the reported incident.

LPA conducted interviews with S1, S2 and conducted interviews with four (4) residents (see confidential names list, LIC 811 dated 4/16/24). LPA obtained the following records: Employment Application for S3, Notes from S1's conversation regarding suspected abuse by R3, declarations from S4, S5, and S6.

LPA has obtained a preponderance of evidence to support S3 did in fact speak inappropriately to residents in care and did not treat residents with dignity and respect including not allowing a resident to get up from their wheel chair.

LPA provided Administrator with copies of LIC 855 (Declaration Form) to be filled out by all staff members who provided written statements regarding suspected abuse by another staff member.

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 facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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 04/16/2024 02:26 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
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: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2024
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements: Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Facility has conducted in service training on mandated reporting and documentation will be submitted to the department by 5:00pm on the POC due date.
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This requirement was not met as evidenced by statements obtained from S1 that a staff member had knowledge of inappropriate behavior by another staff member (cursing, rudeness) towards several residents in care that took place in February 2024 and was not reported to management or the department in a manner that meets regulations which poses an immediate health safety and personal rights risk to residents in care.
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Type B
04/17/2024
Section Cited
CCR87468.1(a)(1)

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Personal Rights of Residents in All Facilities: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by three declarations provided by three staff members who witnessed staff member
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Facility is scheduled to conduct in service training today on employee conduct at the facility and documentation will be submitted to the department by 5:00pm on the POC due date.
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act in an unprofessional manner and cursed and handled residents in a manner that did not treat residents with dignity and respect which poses an potential health safety or personal rights 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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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