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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445294274
Report Date: 07/27/2022
Date Signed: 07/27/2022 04:36:31 PM


Document Has Been Signed on 07/27/2022 04:36 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 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: 23DATE:
07/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Anne RoxasTIME COMPLETED:
04:35 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 facility staff. LPA met with Administrator Anne Roxas (Admin). SOC 341 was submitted to the department by the facility Administrator on Monday, July 25th 2022.

LPA toured the facility and conducted interviews with both residents and staff. In interviews with staff 3 out of 3 staff members stated that they have never witnessed a staff member handling residents roughly nor verbally abusing residents. 3 out of 3 staff members indicated that they are aware of their status as mandatory reporters and that they would report any such incidents. Suspected abuser indicated on the SOC 341 was not currently at the facility to be interviewed.

LPA interviewed 5 residents living at the facility. 5 out of 5 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, 2 out of 5 residents stated that a night shift staff member had been handling them in a rough manner, and was dismissive in his/her demeanor. 2 out of 5 residents' stories were consistent with what was reported by the facility on SOC 341. LPA did not observe visibly apparent physical evidence of abuse on any residents within the facility. Both residents that indicated that a staff member had been handling them in a rough manner stated that they are now receiving care from an alternate staff member, and that there hasn't been issues since the change.

Based on interviews, there is insufficient evidence to make a determination on the allegations at this time. No deficiencies cited today. Exit interview conducted with Administrator Anne Roxas 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: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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