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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 10/12/2021
Date Signed: 10/12/2021 06:01:13 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2021 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20210625140458
FACILITY NAME:ACC MAPLE TREE VILLAGEFACILITY NUMBER:
342700683
ADMINISTRATOR:DEBORAH KANIAFACILITY TYPE:
740
ADDRESS:7579 MAPLE TREE WAYTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 51DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Harumi HurriankoTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Resident sustained multiple severe injuries while in care
INVESTIGATION FINDINGS:
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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 which is to deliver findings of the complaint investigation.

On 6/21/21 Community Care Licensing (CCL) received an incident report regarding this allegation and a complaint was received on 6/25/21 regarding the same incident.

The allegation “Resident sustained multiple severe injuries while in care” was investigated. The investigation revealed that resident #1 (R1) was a 2-person assist for transferring.

On 6/9/21, facility staff noted chest bruises. On 6/10/21, the facility Medical Director physician (MD) conducted a cursory exam on R1 and did not find evidence of fractures or that R1 was in pain. On 6/17/21, R1 was taken to the emergency room (ER) for a change in mental condition and crying in pain.
Unsubstantiated
Estimated Days of Completion: 120
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2021 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20210625140458

FACILITY NAME:ACC MAPLE TREE VILLAGEFACILITY NUMBER:
342700683
ADMINISTRATOR:DEBORAH KANIAFACILITY TYPE:
740
ADDRESS:7579 MAPLE TREE WAYTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 51DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Harumi HurriankoTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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9
Staff did not notify residents authorized representative of incidents
INVESTIGATION FINDINGS:
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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 which is to deliver findings of the complaint investigation.

The allegation “Staff did not notify residents authorized representative of incidents” was investigated. During the interviews, CCL received information that the authorized representative (Responsible Party (RP)) was notified of the incidents that occurred:
-On an unknown date prior to 6/12/21 a nurse from facility notified RP that R1 was in pain,
-On 6/12/21, RP was notified by staff bruises were found:
On 6/15/21, RP contacted the PCP to inquire if R1 should be brought in to be seen, R1 was not taken to ER but seen by MD,
-On 6/16/21, the MD requested R1 be sent to hospital at which time xrays were taken, RP was notified of fractures, R1 was sent back to facility,
Unfounded
Estimated Days of Completion: 120
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210625140458
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/12/2021
NARRATIVE
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-On 6/17/21, R1 was taken to the hospital due to mood changes and the RP was notified by text from the facility staff,
-On 6/21/21, R1 was sent to hospital for slurred speech, staff notified RP,
-On 7/1/21, RP emailed screen shots of the texts received from facility staff regarding the notifications of the incidents.

Based on interviews and medical records and documentation (texts), the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNFOUNDED.

“This agency has investigated the complaint alleging, the above-mentioned allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20210625140458
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/12/2021
NARRATIVE
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The Medical Records revealed that R1 had hematoma and fractured ribs of varying stages of healing. R1 was discharged back to the home the same day. On 6/21/21, R1 was sent to ER again for slurred speech.

An interview with R1-R3 revealed that staff are not rough when handling residents and they have not heard of or seen anyone with bruising or that has been bruised.

Staff stated during interviews that R1 was heavy, fragile, and bruised easily and that they tried many ways to transfer R1 comfortably.

An interview of the MD revealed that R1 did not have any red flags, breathing normally, and that typically a patient with cracked ribs would be in pain. The MD stated that it is not known if this was caused by a single event or several events. The MD contacted R1’s Primary Care Physician (PCP) who indicated R1 is taking baby Aspirin which could contribute to the bruising. The PCP instructed the facility to discontinue the use of the baby Aspirin.

Based on interviews and medical records, the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4