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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004351
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:38:52 PM

Document Has Been Signed on 09/14/2022 12:38 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MAPEL HOUSEFACILITY NUMBER:
347004351
ADMINISTRATOR:TATEISHI, GARYFACILITY TYPE:
735
ADDRESS:4616 MAPEL LANETELEPHONE:
(916) 962-2199
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
09/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Evelyn OrianTIME COMPLETED:
12:45 PM
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On 09/14/2022 at 11:40 AM Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced to conduct a case management investigation. LPA met with caregivers Evelyn Orian and Mary Anne Wilson and explained the purpose of the visit. Prior to initiating the complaint investigation LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

The reason for the visit is an incident report was received from regarding an alleged incident that happened on 09/06/2022 in which a client reported there was a physical altercation with staff.

LPA reviewed the following documents: ongoing notes. LPA interviewed staff working at time of visit: S1 and S2. LPA also interviewed clients C2, C3, and C4. Interviews can be found on the attached LIC812s.

At this point, there are no deficiencies cited during today's visit. LPA will consult with LPM. An exit interview was conducted, and a copy of the report will be provided to facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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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