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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 10/12/2021
Date Signed: 10/12/2021 05:51:28 PM

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:HARUMI HURRIANKOFACILITY TYPE:
740
ADDRESS:7579 MAPLE TREE WAYTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 51DATE:
10/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Harumi HurriankoTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) arrived unannounced to deliver findings of the complaint investigation on 10/12/21 at 2:00pm. LPA met with Harumi Hurrianko and stated the purpose of the visit.

On this subsequent visit, LPA observed that during the complaint investigation, CCL received information that the facility was not incompliance with the Title 22 Regulations. The concerns were that several residents were billed for services not received, medications were not refilled timely, pills were found out of original containers, and prescription medications were found in the pocket of a resident.

LPA interviewed 4 of 7 staff along with 2 of 2 responsible parties regarding the concerns mentioned above.

Based on the interviews, LPA received information that the facility did in fact bill residents for services that were not rendered. Once the interim Administrator became aware of the discrepancies the amounts were refunded in the form of a credit. LPA received information that medications were not refilled timely and pills were found outside of its original container. LPA was also informed that a resident while out with family was found to have prescription pills in a pocket. These deficiencies will be cited on this Case Management visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (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 via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities

To care,...and services that meet their individual needs...
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This requirement is not met as evidenced by: the residents who paid for additional services were billed and the services were not rendered
Based on interviews, confirmed the residents services such as bathing and medication management was not rendered but billed
This violation poses an immediate health, and safety risk to residents in care.
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Type A
10/13/2021
Section Cited

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Incidental Medical and Dental Care

If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
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This requirement is not met as evidenced by: Facility did not refill medications timely. Based on interviews that confirmed, the Licensee did not refill medication or administer medications as prescribed. This possess an immediate health and safety 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited

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Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored:
Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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This requirement is not met as evidenced by: pills were found on the medication cart unlabeled and not prepared for passing
Based on interviews, confirmed the pills were found and not labeled facility did not ensure pills were in its original container
This violation poses an immediate health, and safety risk to residents in care.

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Type A
10/13/2021
Section Cited

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Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed.
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This requirement is not met as evidenced by: medications were found on residents' room floor, in wheelchair bag, and in pocket of resident
Based on interviews, confirmed the pills were found to not have been taken by resident and found later, facility did not ensure medication administration assistance
This violation poses an immediate health, and safety 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021
LIC809 (FAS) - (06/04)
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