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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 04:22:23 PM


Document Has Been Signed on 05/16/2022 04:22 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 arrived unannounced on 5/16/22 at 3pm to conduct a Case Management visit regarding an incident of potential theft by a staff member that possibly occurred between dates of December 2021 to approximately April 2022.

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

LPA and Administrator reviewed Special Incident Reports (LIC624) and Report of Suspected Dependent Adult/Elder Abuse (SOC 341) documents that was submitted to the Department.

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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