372004436-7-26-2021-08-AS-DPOL-C5F2QP-20210730173614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 372004436
Report Date: 05/05/2020
Date Signed: 07/26/2021 10:27:49 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2020 and conducted by Evaluator Evangelica Torres

COMPLAINT CONTROL NUMBER: 08-AS-20200428160752

FACILITY NAME:	MAPLE MANOR		FACILITY NUMBER:	372004436
ADMINISTRATOR:	SNEZANA DJUKIC		FACILITY TYPE:	740
ADDRESS:	1744 SO. MAPLE		TELEPHONE:	(760) 743-0632
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	31	CENSUS: 13	DATE:	05/05/2020
		UNANNOUNCED	TIME BEGAN:	11:58 AM
MET WITH:	Administrator, Djukic Snezana		TIME COMPLETED:	11:59 AM

ALLEGATION(S):

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Licensee violated Resident's #1 personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Eva Torres initiated a virtual visit to investigate the above allegation, due to COVID-19. LPA identified herself and discussed the purpose of the phone call with Administrator, Djukic Snezana. The investigation included interviews with staff and resident's responsible parties.

It was alleged that the licensee violated Resident #1's (R1) (See Confidential Names List, LIC811 for R1) personal rights by preventing them from speaking with their family. The investigation revealed that the facility’s landline is being used more often than normal due to COVID-19. As a result, the licensee provided all residents and their responsible parties with an alternative phone number for anyone attempting to reached residents during normal business hours. Moreover, the interviews conducted with staff and the resident’s responsible parties did not support the allegation, as they confirmed they were always able to reach the facility using the mainline and, or the alternative number. Also, the reporting party confirmed that they were able to schedule a meeting with R1 using the mainline and the alternative number.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Rebecca Hedgecock
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

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 08-AS-20200428160752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MAPLE MANOR	FACILITY NUMBER: 372004436
	VISIT DATE: 05/05/2020

NARRATIVE

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Though the investigation revealed that the facility experience a temporary phone disruption as a result of the phone company working on the phone line, interviews did not reveal the licensee prevented incoming phone calls. Based on the investigation, the Department deemed the evidence insufficient in proving or disproving the allegation occurred. Therefore, the complaint investigation findings are found to be unsubstantiated. An exit interview was conducted with the administrator, and the Licensee’s Rights (LIC9058 01/16) along with a copy of this report was provided to Administrator, Snezana via email. A reply email or return receipt from the administrator will confirm receipt of documents. This is an amended version of the original report that was created on 05/05/20.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Evangelica Torres
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC9099 (FAS) - (06/04)

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