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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 07/30/2026
Date Signed: 07/30/2026 03:19:07 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
10/01/2025 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251001144234
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: 94DATE:
07/30/2026
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Elvyra Abare TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility is not kept in a clean sanitary condition.
Facility is not adequately addressing insect infestation.
facility does not maintain adequate food supply.
facility administered incorrect medications to resident.
INVESTIGATION FINDINGS:
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On July 30, 2026, at 12:00 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Elvyra Abare during today’s visit.

Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and conducted facility tours. The facility was cited Maintenance and Operation 87303 (a) on April 10, 2026, and on May 04, 2026, for the following allegations, pest infestation and facility is not kept sanitary. The facility complied with the April 10, 2026, and May 04, 2026 plan of corrections (POC). The facility continues to follow up on the cleaning plan of correction and pest control plan of correction. Also, Clark Pest Control conducts monthly pest visits and treatments.

Additionally, LPA Martinez toured the facility with staff 1 (S1) on July 30, 2026, and LPA Martinez observed that the facility was sanitary. During the July 30, 2026, tour, LPA Martinez did not observe any pest.
Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026
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 2
Control Number 27-AS-20251001144234
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: 07/30/2026
NARRATIVE
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Moreover, during the July 30, 2026, facility tour, LPA Martinez inspected the facility kitchen with staff 1. LPA Martinez observed that the facility had an adequate food supply. LPA Martinez has also been receiving weekly menus and food supply invoices since June 02, 2026. The facility staff has continued to follow up with ensuring that the facility has an adequate food supply.

LPA Martinez reviewed resident 1's (R1) October 2025, medication administration record (MAR) and medication notes. The MAR did not indicate that there were any medication errors. R1's medication administration notes did indicate that there were any medication errors.

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: 07/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2