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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 05/04/2026
Date Signed: 05/04/2026 02:55:47 PM

Document Has Been Signed on 05/04/2026 02:55 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/
DIRECTOR:		YESENIA JONESFACILITY TYPE:
740
ADDRESS:18 KADO CTTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 125CENSUS: 93DATE:
05/04/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:YberraTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Manager (LPM) Liza King and Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility to deliver complaint findings. LPA and LPM met with Elvyra Abare whom identified themselves as the newly appointed Executive Director. During todays visit verification of fingerprint and association was conducted to ensure the individual was cleared to be present and working in the facility. Current census 68 in Assisted Living and 28 in Memory Care, 2 residents on hospice throughout the building.
For Admin changes, the RO requests the following documentation to be submitted by 05/06/26

· A letter from the licensee and/or Board appointing the individual as the Administrator


· LIC308
· Copy of current Admin Cert
· Any documentation that meets the education and/or experience requirements, if applicable
· LIC 200 signed by the licensee or designee
· LIC 500 to indicate the days/hours the administrator is in the facility
· LIC 501 so that we can determine if the Admin meets the education/ experience requirement.

cont.
NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/04/2026
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A tour of the facility was conducted. Residents in the memory care (MC) neighborhood appeared clean and well kept, breakfast service was concluding, then residents were engaged in a sing along followed by exercises. Five rooms were entered, 5/5 rooms contained personal care supplies. 1/5 rooms contained cleaning supplies; tide pods-this rooms door was propped open. Interview with a caregiver deemed the facility does not have a practice in place to determine which residents are allowed access to personal care supplies and which are not. Additionally, cleaning supplies were observed under the sink in an unlocked cabinet. A ladder and tool case with various tools were left unattended. Staff belongings including purses and backpacks were left accessible to residents. These practices present an immediate risk to residents in care. A discussion occurred with the Administrator whom acknowledged the issue. A review of staff training records revealed an inservice had occurred over the past 30days re: accessibility to cleaning solutions and toxins. On the MC patio a long metal rod was observed. A pull cord was pulled in the MC area. After not being addressed for several minutes LPM observed that the volume was muted on the device which alerts staff a pull cord has been pulled. Review of a second device showed the same volume setting. 4 resident files were reviewed. 1/4 documented the resident was not allowed access to personal supplies, additionally 1/4 documented lack of safety awareness and impulsivity and able to have access which may be contradictory. LPM recommends reviewing this documentation throughout the MC area and creating a plan to ensure those that would be at risk are protected and staff are knowledgeable. Diet orders were verified against the resident physician orders and notification to care staff which is posted in a conspicuous place for the staff to refer to with no concerns. Water temp was within regulatory range. No odor was present and the area appeared clean and well-kept, except for the refrigerator which should be wiped down. Recommendation is to establish a cleaning schedule for the communal and private refrigerators throughout the building. Communal bathrooms were clean.

Observations were conducted on the Assisted Living (AL) side at lunchtime. Live music was being performed prior to lunch service. Water temp was within regulatory range. Eight rooms were entered and met regulatory requirements. No odor was present and the communal area appeared clean and well-kept, except for two communal refrigerators which should be wiped down. Recommendation is to establish a cleaning schedule for the communal and private refrigerators throughout the building. Communal bathrooms were clean.

cont

NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/04/2026
NARRATIVE
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Observation in the kitchen area showed dead carcasses of bugs, guidance was provided in establishing a routine cleaning schedule behind appliances and corners of rooms. Additionally, garbage can lids on the exterior of the building are not being closed which attracts insects and rodents.

Additionally, the following documentation was reviewed and are of no concern at this time

· Backflow Testing conducted 07/01/2025

· Ansul Semi Annual Inspection 10/17/2025

· Fire Alarm Annual Inspection and Testing 10/17/2025

· Annual Sprinkler Testing 10/17/2025

· Elevator Inspection 10/28/2025

· Disaster Plan inc Earthquake, Relocation, Communication, Pandemic, Power Failure, Active Shooter, Bomb Threats, Infection Control Plan and LIC610. Provided a new Administrator is present it is recommended a review of the above and documentation.

The above information is not all inclusive of todays visit, this information and these observations are in addition to those being cited on complaint visit reports dated today.

Citations are being issued as a result of these observations and findings and an exit interview was conducted with Elvyra Abare. Appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/04/2026 02:55 PM - It Cannot Be Edited


Created By: Liza King On 05/04/2026 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ACC MAPLE TREE VILLAGE
FACILITY NUMBER: 342700683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2026
Section Cited
CCR
87309(b)

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(b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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Immediate dangers were removed or fixed during todays visit. The Admin will conduct training with all staff within 2 weeks.
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This was not met as evidenced by cleaning supplies being accessible to residents in care which poses an immediate health and safety risk to clients in care.
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Type B
05/18/2026
Section Cited
CCR87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times.
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The Admin will conduct a training of Supervisors and staff within 2 weeks then conduct unannounced checks.
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This was not met as evinces by dead bug carcuses being observed, communnal refridgerators not being clean and did not have a freezer thermometer, trashcan lids being open
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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.
Krystall Moore
NAME OF LICENSING PROGRAM MANAGER:
Liza King
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2026


LIC809 (FAS) - (06/04)
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