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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294274
Report Date: 05/04/2022
Date Signed: 05/04/2022 05:05:08 PM


Document Has Been Signed on 05/04/2022 05:05 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MAPLE HOUSE II, THEFACILITY NUMBER:
445294274
ADMINISTRATOR:CHEN, HONG-GENFACILITY TYPE:
740
ADDRESS:2000 BROMMER STREETTELEPHONE:
(831) 476-6366
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:40CENSUS: 21DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Mary Jean ArcegaTIME COMPLETED:
05:05 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit in response to a self reported case of alleged resident abuse by staff. LPA met with House Manager Mary Jean Arcega (Admin). SOC 341 was submitted to the department by the facility Administrator on Monday, May 2nd 2022.

LPA toured the facility and conducted interviews with both residents and staff. In interviews with staff 6 out of 6 staff members stated that they have never witnessed a staff member striking or otherwise harming a resident in care. 6 out of 6 staff members indicated that they are aware of their status as mandatory reporters and that they would report any such incidents. Admin indicated that R1 and the suspected abuser (SA) have been separated, and that SA is currently instructed not to interact with R1. SA was not currently at the facility to be interviewed.

LPA interviewed 6 residents living at the facility. 5 out of 6 residents stated that they enjoy living at the facility and that they believe staff is providing satisfactory service. When asked if they could think of any incidents in which staff harmed residents in any capacity, 1 out of 6 residents stated that they had. R1 stated that he/she had unintentionally set off the alarm system in his/her room, and that when staff arrived, they shouted at him/her "in their mother tongue" before striking him in the back of the head in frustration. R1's story was consistent with what was reported by the facility on SOC 341. LPA did not observe visibly apparent physical evidence of abuse on R1's person. R1 first reported the incident to his home health nurse (HHN1). LPA attempted to reach out to HHN1 via phone, but has yet to hear back from them.

Based on interviews, there is insufficient evidence to make a determination on the veracity of the allegations at this time. No deficiencies cited today. Exit interview conducted with House Manager Mary Jean Arcega and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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