342700683-8-18-2026-27-AS-APAA-DXCSHD-20260827135319

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 08/18/2026
Date Signed: 08/18/2026 02:17:55 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
10/08/2025 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20251008103543

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: 91	DATE:	08/18/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Ylvyra Abare		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not provide medication assistance to resident in care.
Staff is not properly trained.
Staff did not conduct a proper assessment of resident in care.
Staff overcharged resident in care.

INVESTIGATION FINDINGS:

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On August 18, 2026, at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the unannounced facility to deliver complaint findings. LPA Martinez met with Ylvyra Abare during today’s visit and explained the purpose of this inspection visit.

Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and resident records.

LPA Martinez conducted interviews with four out of four facility staff. Four out of four facility staff reported that resident 1 (R1) was assisted with their medication and hospice staff administered R1's controlled PRN medications. LPA Martinez also reviewed medication administration notes, which indicated medication was being administered to R1 with no documented issues.

Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20251008103543

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: 08/18/2026

NARRATIVE

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LPA Martinez reviewed board and care invoice statements, the resident functional evaluation, and facility notes. Based on the documentation reviewed, staff 1 (S1) conducted a reassessment on September 21, 2025, and a facility note indicates R1's family was made aware of the reassessment and rate change. Moreover, R1's LIC 602 Medical Assessment for Residential Care Facilities for the Elderly was updated after R1's change in condition and reflected R1's change in condition care needs.

LPA Martinez also reviewed 2025, yearly in-service training documents. Facility staff were trained on basic care services and incidental medical and dental. 3 out of 3 staff reported that they were properly trained, and reported they received hospice training.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

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