445294274-10-27-2024-26-AS-KHOS-DARNGL-20241106092718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294274
Report Date: 10/27/2024
Date Signed: 10/27/2024 06:24:22 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20220921121437

FACILITY NAME:	MAPLE HOUSE II, THE		FACILITY NUMBER:	445294274
ADMINISTRATOR:	CHEN, HONG-GEN		FACILITY TYPE:	740
ADDRESS:	2000 BROMMER STREET		TELEPHONE:	(831) 476-6366
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	40	CENSUS: 21	DATE:	10/27/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Anshu Gupta		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident fell due to lack of supervision.

Resident disrupting multiple resident’s sleep.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 10/27/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by a facility staff person, Randeep Uppal, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Anshu Gupta, to inform her that CCL was present at this time.
The facility designated Administrator, Anshu Gupta, arrived shortly thereafter to this facility while this LPA was conducting this visit. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 21 residents.
The purpose of todays visit was to complete this investigation and deliver the findings to this facility, and it's representative, at this time.
Based on a review of the facility documents, it was learned this facility employed (3) shifts covering the morning (AM), afternoon (PM), and night (NOC) hours of operation. It was learned that the AM shift started at 06:30 am to 03:00 pm. The PM shift spanned from 03:00 pm to 11:30 pm. The NOC shift covered the

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2024

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 26-AS-20220921121437

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: MAPLE HOUSE II, THE	FACILITY NUMBER: 445294274
	VISIT DATE: 10/27/2024

NARRATIVE

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hours of 11:00 pm to 07:00 am.
It was learned that there were (2) staff members scheduled for each shift at all times. In addition, there was a medication technician on schedule daily from the hours of 09:00 am to 06:00 pm. This particular individual who handled and dispensed the medications was also trained as care staff who would be available to assist with resident care if needed.
It was learned that during regular business hours of operation (09:00 am to 05:00 pm), there were administrative staff also present such as the facility designated Administrator, Assistant Administrator, and House Manager who were able to step in and provide support for care and supervision to the residents if needed.
Based on interviews conducted during this investigation, it was learned that this facility has a current hospice waiver to be able to accept and retain up to (10) residents at any given time. It was learned that this facility currently had (5) residents under the care of hospice at this time.
Based on interviews conducted during this investigation, it was learned that resident care and supervision being provided was satisfactory without any complaints at this time. There weren't any concerns in regards to disruptions from one resident to another preventing proper sleep and rest. It was learned that staff were readily available to handle any situations should they arise in regards to resident well being.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2024

LIC9099 (FAS) - (06/04)

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