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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202946
Report Date: 11/07/2025
Date Signed: 11/07/2025 01:57:13 PM

Document Has Been Signed on 11/07/2025 01:57 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MAPLE HOUSE IIFACILITY NUMBER:
445202946
ADMINISTRATOR/
DIRECTOR:		ROXAS, ROSE ANNEFACILITY TYPE:
740
ADDRESS:2000 BROMMER STREETTELEPHONE:
(831) 476-6366
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 40CENSUS: 22DATE:
11/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator Rose-Anne Roxas
Administrator Anshu Gupta		TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management visit to follow up on an incident report, which stated a resident had eloped from the facility. LPA met with Administrators (ADMs) Rose-Anne Roxas and Anshu Gupta. LPA stated the purpose of the visit.

Elopement 10/29/2025

On 10/31/2025 the Department received an incident report regarding a resident (referred to as R1) who eloped from the facility on 10/29/2025. According to the report, on 10/29/2025 around 5:45PM, R1 'went outside of the facility unattended from his/her room while staff was helping the other residents in the dining room, when they heard the beeper, staff starting looking for the resident and they found out that R1 is not inside his/her room. They went outside the facility and saw R1 walking and took him back inside the facility."

On 10/31/2025 Licensing Program Analyst (LPA) Maria 'Mita' Partoza interviewed Administrator (ADM) Anshu Gupta. ADM stated R1 eloped from the facility between 5:45PM and 5:47PM. ADM stated R1 had finished eating dinner, stood up and went to his/her room. ADM stated a staff member went with R1 to his/her room and placed a tab alarm device on R1, and the staff then went back to the kitchen to assist with other residents. ADM stated there were additional staff on shift, including the cook when the elopement occurred. ADM initially stated it took staff '3 to 4 minutes' to respond to the alarm (beeper). ADM then stated staff responded immediately to the alarm (beeper). ADM stated she observed R1 at the facility when she arrived at approximately 6:00PM. ADM stated R1 was located on the next street over from the facility.

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NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: MAPLE HOUSE II
FACILITY NUMBER: 445202946
VISIT DATE: 11/07/2025
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On 11/5/2025 LPA Tarin interviewed ADM Anshu Gupta. ADM stated on 10/29/2025 R1 had removed his/her tab alarm, but R1 was also wearing a Wanderguard, which alarmed when R1 exited the facility. ADM stated staff located R1 on the sidewalk corner of Chanticleer Ave and Brommer Street. ADM stated R1 walked right onto Brommer Street and walked to Chanticleer Ave, where staff found him/her. ADM stated R1 was returned back to the facility and R1's responsibly parties were informed. ADM states R1 was not injured during the elopement.

Based on a Google Map search, staff located R1 on the sidewalk of a 4 way intersection approximately 400 feet from the facility.



On 11/7/2025, LPA interviewed Administrator (ADM) Rose-Anne Roxas. ADM stated R1 walked out through the facility front door on 10/29/2025. ADM demonstrated the path which R1 took when he/she eloped from the facility on 10/29/2025. ADM walked LPA Tarin through R1's elopement path, through the facility front door, and out to the front of the facility, which leads to Brommer Ave. LPA observed there is no sidewalk leading to Chanticleer Ave, only a bike lane, next to 2 street lanes.

LPA interviewed R1. R1 did not provide additional information due to neurocognitive disorder.

Based on a review of R1’s Physician’s report, dated 10/2/2025, R1 has neurocognitive disorder and cannot leave the facility unsupervised. R1's Needs and Service Plan dated 10/14/2025, R1 is "forgetful, disoriented, fall risk, and increased cognitive decline."

A Deficiency was cited per California Code of Regulations, Title 22 during today’s visit, see LIC809-D.
An exit interview was conducted with Administrators Rose-Anne Roxas and Anshu Gupta. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2025 01:57 PM - It Cannot Be Edited


Created By: Marcella Tarin On 11/07/2025 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MAPLE HOUSE II
FACILITY NUMBER: 445202946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2025
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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ADM stated she will send a written plan of action on how the facility will ensure residents with neurocognitive disorder will be kept safe. ADM stated he will also send a written letter of understanding regarding the regulation. ADM will submit POC to CCLD by POC due date 11/8/2025
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Based on record review and interviews, R1 cannot leave the facility unsupervised. R1 left the facility unsupervised on 10/29/2025, which poses an immediate health, safety and personal rights risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2025


LIC809 (FAS) - (06/04)
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