347004351-6-9-2023-25-AS-APEZ-CT3UHR-20230623153619

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004351
Report Date: 06/09/2023
Date Signed: 06/09/2023 11:29:43 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
10/11/2022 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 25-AS-20221011161704

FACILITY NAME:	MAPEL HOUSE		FACILITY NUMBER:	347004351
ADMINISTRATOR:	TATEISHI, GARY		FACILITY TYPE:	735
ADDRESS:	4616 MAPEL LANE		TELEPHONE:	(916) 962-2199
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Edmon Orian and Freddie Galvez		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident was physically assaulted by another resident in care.

INVESTIGATION FINDINGS:

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On 06/09/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility and met with Facility Manager, Edmon Orian, and Caregiver, Freddie Galvez, to deliver findings into the allegation listed above. LPA explained the purpose of the visit. Additionally, LPA wore a surgical mask to ensure the health and saefty of clients in care.

During the investigation, LPA conducted interviews and records review.

The results of the investigation are as follows:

Allegation: Resident was physically assaulted by another resident in care.

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221011161704

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: MAPEL HOUSE	FACILITY NUMBER: 347004351
	VISIT DATE: 06/09/2023

NARRATIVE

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Continued from LIC 9099...

Allegation: Resident was physically assaulted by another resident in care.
The Department conducted record review and interviews to investigate this allegation. Interview conducted with S1 indicated that C1 and C2 had an altercation while other clients in care were being helped to their rooms. During interview with S1 and S2 indicated that C1 spat at C2, who then punched C1 in the face with C2's fist. In interview with C2, C2 informed LPA C2 pushed C1 after C1 stated "your mama". In interview conducted, C2 stated after C2 pushed C1, C1 then spat at C2, which resulted to C2 punching C1 in the face. During records review, LPA observed that C1 received medical services after the incident.

Based on interviews and records review, LPA finds that the allegation cited above is Substantiated.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

No deficiencies will be cited as during interviews conducted with S1, S2 and C2, staff intervene immediately when incident occurred. Facility conducted a preventative plan to separate C1 and C2.

Exit interview with Caregiver. Appeals rights provided. Copy of the report provided to facility.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

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