342700683-5-20-2025-27-AS-KHOS-DHRH5H-20250618055334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 05/20/2025
Date Signed: 05/20/2025 03:43:57 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
03/28/2025 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20250328131444

FACILITY NAME:	ACC MAPLE TREE VILLAGE		FACILITY NUMBER:	342700683
ADMINISTRATOR:	YESENIA JONES		FACILITY TYPE:	740
ADDRESS:	18 KADO CT		TELEPHONE:	(916) 395-7579
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	125	CENSUS: 92	DATE:	05/20/2025
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ysenia Jones		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1) Staff do not ensure kitchen is kept in sanitary conditions.
2) Staff do not ensure expired food is properly discarded
3) Staff do not ensure perishable food is properly stored
4) Staff do not ensure food served to residents is of good quality
5) Staff do not follow food service sanitation practices which protect the food from contamination.

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 5/20/25 at 12:30pm 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 conducted two unannounced kitchen inspections and observed no violations of title 22 regulations in terms of food service or storage. LPA conducted interviews with three kitchen staff members, multiple residents eading lunch and the RP. All staff interviewed denied the allegations listed above. Residents informally interviewed during lunch had no objections to the quality of food provided, most informally questioned had positive outlook on the food being provided. Report Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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 2

Control Number 27-AS-20250328131444

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: 05/20/2025

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

LPA conducted an interview with RP who did not provide many specifics other than food items being left out for extended periods of time and states there are picture to support the allegations. At the time of writing LPA still has yet to receive documentation from Reporting Party. LPA reviewed 3rd party audits and reviewed two recent reports from the auditing agency dated February 2025 and May 2025. Per the audit reports, the initial February audit the facility received a score of 87 percent with recommendations for deep cleaning in some areas but related to the allegations described. The audit found no errors or deficiencies with food storage/preparation. The second audit dated May 2025 the kitchen received a score of 98 percent with all deep cleaning items addressed.

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 Food Service 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.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2