342700683-10-14-2021-27-AS-SRIN-C7WRB3-20211018125204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 09/28/2021
Date Signed: 10/14/2021 03:39:18 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
05/24/2021 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210524145050

FACILITY NAME:	ACC MAPLE TREE VILLAGE		FACILITY NUMBER:	342700683
ADMINISTRATOR:	DEBORAH KANIA		FACILITY TYPE:	740
ADDRESS:	7579 MAPLE TREE WAY		TELEPHONE:	(916) 395-7579
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	125	CENSUS: 50	DATE:	09/28/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Harumi Hurrianko		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained a fracture while in care
Resident sustained unexplained bruises while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Valerio was screened for COVID-19 symptoms prior to being allowed entry into the facility. LPA Valerio explained the purpose of the visit and was met by Administrator Harumi Hurrianko.

The investigation was conducted by LPA Valerio. The investigation consisted of interviews with the resident's responsible parties (RPR3 and RPR4), interview with current administrator, review of Medical records, and review of facility records.

The Department has determined the following as it relates to the allegations: Resident sustained a fracture while in care and Resident sustained unexplained bruises while in car

Continued on LIC 9099-C...
This page was amended to disclose two substantiated allegations
Page 1 of 2

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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

Control Number 27-AS-20210524145050

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: 09/28/2021

NARRATIVE

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..Continued from LIC 9099

LPA Valerio reviewed four random resident files. The resident files reviewed were residents present during the month of April 2021 and May 2021. Based on the review the resident's LIC 602 Physician Report, Incident Reports, and medical records, LPA Valerio observed 2 out of 4 residents sustaining injuries. R2 sustained multiple rib fractures after an incident involving a fall. R3 sustained three rib fractures, unexplained bruising on arms, unexplained bruising under breast, and unexplained bruising on body. LPA Valerio later discovered from an interview conducted with Responsible Party for Resident 4 (RPR4) that R4 sustained injuries while in care at ACC Maple Tree Assisted Living. RPR4 removed the resident from the facility based on R4's doctor recommendation. R4, whom was non-ambulatory, was left alone in R4's room causing R4 to fall. R4 sustained bruising along arms and body, a rib fracture, and face injuries, which required sutures.

Based on medical record review, interview, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An immediate $500 penalty is being issued today.

At the time of the conclusion of this complaint investigation, the issuance of a Civil Penalty was still being determined. However, the Licensee was informed that a Civil Penalty may be assessed based on Health & Safety Code section 1569.49 (1).

An exit interview was conducted, and a copy of the report was provided to Administrator Harumi Hurrianko.

This document was amended to include an issuance of an immediate $500 penalty and to disclose that an issuance of a Civil Penalty was still being determined.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC9099 (FAS) - (06/04)

Page: 4 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
05/24/2021 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210524145050

FACILITY NAME:	ACC MAPLE TREE VILLAGE		FACILITY NUMBER:	342700683
ADMINISTRATOR:	DEBORAH KANIA		FACILITY TYPE:	740
ADDRESS:	7579 MAPLE TREE WAY		TELEPHONE:	(916) 395-7579
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	125	CENSUS: 50	DATE:	09/28/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Harumi Hurrianko		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff are not adequately trained

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Harumi Hurrianko and explained the purpose of the visit. The Department has determined the following as it relates to the allegations: Staff are not adequately trained

LPA Valerio requested facility documentation regarding staff training. Relias online training and in-service training were provided for the months of 02/2021 - 09/2021. LPA observed training regarding Medication, Dementia Care, Abuse, ADLs, First Aid, Behaviors, and COVID-19. Based on staff interviews (S1-S2), staff confirmed the signatures on the in-service training were their signatures and they received the training.

Based on facility documentation and staff interviews, the aforementioned allegation is unfounded and the allegation false. There are no citations for this allegation. An exit interview was conducted, and a copy of the report was provided to Administrator Harumi Hurrianko.

This document was amended to remove the 9099D page as there are no citations for this allegation.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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-20210524145050

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 09/29/2021 Section Cited CCR 87411(c)	1 2 3 4 5 6 7	87411(c) Personnel Requirements – General. Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee stated on-going education will be provided to direct care staff regarding care and supervision. The licensee will provide training on Proper Transferring of Residents by POC due date. Licensee will send a copy of sign in sheet with staff signatures to LPA Valerio.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the Licensee did not provide adequate supervision to 3 out of 4 residents, which resulted in residents sustaining injuries from falls. This poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type A 10/15/2021 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (2) The licensee shall provide assistance in meeting necessary medical...needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee stated there will be a plan put in place to review all resident's care plan to ensure they meet the needs of resident's health care needs by POC due date. Licensee has a point click care system in place that requires staff to review plan of care for each resident for each shift.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the licensee did not follow the care plan for 2 out of 4 residents in care, which resulted in residents sustaining unexplainable bruising and fractures. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	This document was amended to include a second citation.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC9099 (FAS) - (06/04)

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