Maple House II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Rose Anne Roxas. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with ADM to include but not limited to the the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 35 F and Freezer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. The smoke detectors were inspected by a third party vendor on 9/17/2025 and passed inspection. Fire extinguishers were last serviced on 3/10/2025. The facility emergency drill log was reviewed. The facility's last drill was on 11/26/2025. LPA toured 5 random resident bedrooms. All 5 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 5 bathrooms. All 5 bathrooms had hand soap, paper towels and covered trash bins. LPA measured water temperature with a range of 116.2 F to 118.7 F. Page 1 of 2. During inspection, LPA followed up on a deficiency issued on 11/7/2025 regarding the elopement of a resident on 10/29/2025. The POC was received by the POC due date 11/8/2025. LPA tested 3 exit doors in the facility and observed 3 out 3 exit doors to have an auditory alarm when tested by the ADM. LPA also reviewed staff training, conducted on 11/5/2025 to include Resident's Wandering (Dementia). A Letter of Deficiency Citations Cleared was provided during the visit today. LPA reviewed 3 resident records and 2 Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 3 staff records. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Administrator Rose Anne Roxas and a signed copy of this report was provided. Page 2 of 2. END OF REPORTthe state’s words, verbatim · CDSS document, Dec 12, 2025

Type of visit: Case Management - Incident

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. Page 1 of 2 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.the state’s words, verbatim · CDSS document, Nov 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 8, 2025

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: 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.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: 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

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Marcella Tarin and David Marrufo arrived unannounced to conduct a pre-licensing visit to follow up on corrections and deficiencies that were observed on 10/22/2024 during a previous pre-licensing visit. On 10/22/2024 during a pre-licensing visit with LPAs Mita Partoza and Marcella Tarin, deficiencies were observed and documented in the Pre-Licensing report. LPAs observed the dishwasher in the kitchen was corroded and 2 parking lot cement stoppers were cracked. The current licensee needed to address that equipment and that the physical plant are in good repair with no breaks, cracks or chips. On 10/23/2024 the facility submitted pictures of the removal of the parking lot cement stoppers. On 12/11/2024, LPAs observed there were no broken parking lot cement stoppers in the parking lot. LPAs also observed the dishwasher to be free of corrosion. Applicant states the facility is in the process of replacing the current dishwasher with a new one. LPAs reviewed the Fire Safety Inspection Request dated 11/04/2024, which indicated a capacity for 8 bedridden residents. The LIC200 Application for a Community Care Facility or Residential Care Facility for the Elderly License indicated a bedridden capacity for 15. LPAs advised applicant to re-submit the LIC200 to Centralized Application Bureau (CAB) for the bedridden increase request. During visit, LPAs reviewed Component III with Applicant Anshu Gupta. No deficiencies were cited today per California Code of Regulations Title 22. This report was reviewed with Applicant Anshu Gupta and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 11, 2024

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Marcella Tarin and Maria (Mita) Partoza arrived unannounced to conduct the facility's pre-licensing visit. LPAs met with Anshu Gupta (Vice President/Applicant) and Rose Anne Roxas (House Manager/Administrator). There are 21 residents present on site. This facility address is currently licensed (435294274) and is under a change of ownership. During visit, LPAs toured the inside and outside of the facility to include the kitchen, dining, living room, garage, activity room, 22 resident rooms, 2 staff rooms, 1 office room. 6 out of 22 resident rooms have shared bathrooms. 1 out of 22 resident rooms are shared. 21 out of 22 residents’ rooms are single occupancy. All fire exit routes were free and clear of obstruction. LPAs observed 5 storage sheds located on the back and side perimeters of the facility. All 5 sheds are used for storage and not habitual space. Toxins observed secured. Facility has a laundry area inaccessible to residents. Each resident room has their own exit doorway leading out to the perimeter. 16 cameras were observed in public areas: lobby, driveway (Parking lots), facility hallways, exit doors, and all-around perimeter of the facility, kitchen area, and laundry. No cameras were observed in resident rooms, 16 cameras were observed in total throughout the facility. No bodies of water were observed. Bathrooms supplied with hygiene products and paper supplies. LPAs observed the smoke and carbon monoxide detectors to be in working condition. Hot water temperature maintained between 112.4 to 116.9 degrees Fahrenheit. Facility temperature maintained at 73 degrees Fahrenheit. First aid kit supplied with tweezers, bandages, gauze, scissors, and thermometer. Medications are stored in a locked cabinet. See 809-C LPAs observed a nonperishable food supply of 7 days and a perishable food supply of 2 days. LPAs observed sharp supplies in a locked cabinet in the kitchen. The following posters observed to include the emergency telephone numbers, personal rights, and facility sketch. Fire extinguisher was inspected on 03/13/2024. Areas of corrections were discussed during today's visit with the applicant, such as the facility sketch and the Emergency Disaster Plan (LIC610E). LPAs observed the dishwasher in the kitchen was corroded and 2 parking lot cement stoppers were cracked, current licensee, needs to address that equipment and that the physical plant are in good repair with no breaks, cracks of chips. Pre-Licensing is incomplete with corrections/deficiencies to be resolved by 11/6/2024. The applicant stated an order for a dishwasher has been placed. A follow up Pre-licensure LIC809 will be generated upon resolution of corrections/deficiencies. An exit interview was conducted with Anshu Gupta (Vice President/Applicant) and Rose Anne Roxas (House Manager/Administrator. No deficiencies were cited. A copy of this report was provided to Anshu Gupta. End of reportthe state’s words, verbatim · CDSS document, Oct 22, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 40 Census (if any clients in care): COMP II Participants: ROSE ANNE ROXAS/ADMINISTRATOR Interview Method: Telephone interview On 9/16/24, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Sep 16, 2024