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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 04/24/2024
Date Signed: 04/24/2024 02:10:15 PM


Document Has Been Signed on 04/24/2024 02:10 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: 88DATE:
04/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Yesenia JonesTIME COMPLETED:
02:30 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
On 4/24/24 at 9:45am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to gather additional information regarding an incident report received by the department on 4/15/24. LPA met with administrator Yesenia Jones.

LPA met with Administrator and Resident Care Coordinator to gather additional information and documents regarding reported incidents. LPA obtained names, address and contact information for four (4) staff members. R1's physician report, fall history, and companion information. Termination letter for S1 and discipline letter for S2. LPA also obtained LIC 500.

Exit interview was conducted with facility staff 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: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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