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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 01/08/2026
Date Signed: 01/08/2026 02:53:03 PM

Substantiated


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
10/15/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20251015162429
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: 86DATE:
01/08/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Yesenia JonesTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Physical Pant: Staff did not ensure the facility was free of pests
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to ACC Maple Tree Village RCFE on 1/8/26 at 9:15am 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. LPA condcuted a walkthrough with the maintenance director of kitchen and food storage areas. When inspecting the kitchen dry storage area, LPA observed grains of rice on the floor and pieces of uncooked pasta unsealed on storage shelves. LPA moved a box and observed a rodent feces on the shelves next to sealed food items. LPA instructed kitchen staff to pull all items and deep clean the dry storage area. While the facility has continued services with pest control and even change pest control services the kitchen staff are not ensuring the kitchen area is being appopriatly cleaned and food stored to ensure pests are not attracted to the kitchen. Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026
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 3
Control Number 27-AS-20251015162429
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: 01/08/2026
NARRATIVE
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Physical Plant is substantiated.

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: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20251015162429
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: 01/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2026
Section Cited
CCR
87555(b)(27)
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General Food Service Requirements: All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by LPA observations of rodent droppings in the kitchen dry storage area which poses a potential health, safety and personal rights
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The administrator has agreed to develop an updated kitchen cleaning plan that address a more detailed daily, weekly and monthly cleaning plan for the kitchen and will assign specific tasks to specific kitchen staff to ensure the kitchen is clean and does not continue to attract rodents in the kitchen.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3