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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700683
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:03:35 PM


Document Has Been Signed on 09/29/2022 04:03 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:BRENDA CHAPPELLFACILITY TYPE:
740
ADDRESS:18 KADO CTTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 59DATE:
09/29/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Brenda ChappellTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Victoria Brown and Dana Garcia, Associate Governmental Program Analyst (AGPA) arrived unannounced to conduct a Post Licensing visit on 9/29/22 at 1:30PM. Administrator Certificate expires 4/25/2023. LPA met with Brenda Chappell, Administrator regarding the purpose of todays visit. The facility is licensed for a capacity of 125 Non-Ambulatory residents. A Hospice Waiver was approved to allow 15 residents to receive hospice care services. Currently there is 1 resident receiving hospice services.

LPA, AGPA, and Administrator toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed residents during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed at 73*F which is within the required range of 68-85*F. The hot water temperature was measured in a random amount of rooms to be at 109.8*F which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents.
The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Liability Insurance
Personnel Report (LIC500)

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited during this visit. An exit interview was conducted. A copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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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