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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 05/16/2022
Date Signed: 05/16/2022 04:21:52 PM


Document Has Been Signed on 05/16/2022 04:21 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ACC MAPLE TREE VILLAGEFACILITY NUMBER:
342700683
ADMINISTRATOR:HARUMI HURRIANKOFACILITY TYPE:
740
ADDRESS:18 KADO CTTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 60DATE:
05/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Harumi HurriankoTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/16/22 at 3pm on a subsequent Case Management visit.

LPA met with Administrator Harumi Hurrianko and stated the purpose of the visit.

LPA and Administrator reviewed Special Incident Report (LIC624) that was submitted to the Department on 9/28/2021 that indicated there was a medication error on 9/19/2021.

Resident #1 (R1) was missing medication because it was mistakenly administered to R2.

LPA received information that the staff involved is no longer working for the facility. LPA requested contact information for the staff, In-service documents, and medication records.

This incident needs further investigation.

Community Care Licensing (CCL) will return on a later date to complete the investigation after further review.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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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