Acc Maple Tree Village

Allegation investigated: Staff leave resident soiled for an extended period of time. Staff does not ensure to provide resident adequate clothing. facility is not meeting residents physcian ordered special diet of pureed foods. Staff leave resident soiled for an extended period of time. Staff is mismanaging resident's medications.

On August 18, 2026, at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the unannounced facility to deliver complaint findings. LPA Martinez met with Ylvyra Abare during today’s visit and explained the purpose of this inspection visit. Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and resident records. Based on a record review, there was not sufficient evidence to support that resident 1 (R1) was left soiled for an exteneded period of time. Four out four facility reported that R1 was not left in soiled clothing or breifs. Three out four care staff reported R1 was assisted with dressing and was always fully clothed. Additionally, there were no documented incidents of R1 not having clothes or missing clothing. It was learned that there were no documented incidents regarding R1 not being provided pureed foods. Continued... Unsubstantiated LPA Martinez reviewed medication administration notes. The notes indicated that facility staff were contacting R1's hospice agency regarding medication refills and filling new medication orders. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegation are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 18, 2026 · control 27-AS-20250922083919

Allegation investigated: Staff did not provide medication assistance to resident in care. Staff is not properly trained. Staff did not conduct a proper assessment of resident in care. Staff overcharged resident in care.

On August 18, 2026, at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the unannounced facility to deliver complaint findings. LPA Martinez met with Ylvyra Abare during today’s visit and explained the purpose of this inspection visit. Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and resident records. LPA Martinez conducted interviews with four out of four facility staff. Four out of four facility staff reported that resident 1 (R1) was assisted with their medication and hospice staff administered R1's controlled PRN medications. LPA Martinez also reviewed medication administration notes, which indicated medication was being administered to R1 with no documented issues. Continued... Unsubstantiated LPA Martinez reviewed board and care invoice statements, the resident functional evaluation, and facility notes. Based on the documentation reviewed, staff 1 (S1) conducted a reassessment on September 21, 2025, and a facility note indicates R1's family was made aware of the reassessment and rate change. Moreover, R1's LIC 602 Medical Assessment for Residential Care Facilities for the Elderly was updated after R1's change in condition and reflected R1's change in condition care needs. LPA Martinez also reviewed 2025, yearly in-service training documents. Facility staff were trained on basic care services and incidental medical and dental. 3 out of 3 staff reported that they were properly trained, and reported they received hospice training. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 18, 2026 · control 27-AS-20251008103543

Type of visit: Case Management - Other

On August 18, 2026, at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived unannounced at the facility to conduct a case management inspection. LPA Martinez met with Ylvyra Abare and explained the purpose of today’s visit. The purpose of the visit today, is in response to a refund deficiency. It was learned that resident 1 (R1) was not provide a refund in a timely manner. R1 moved out of this facility in 2025. R1 was not issued a refund within fifteen days of removing their belongings out of the facility. R1 was refunded $275.36 in July of 2026. As a result of this case management inspection, the following deficiency was cited Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds:1569.652 (c). The deficiency can be found on 809-D Page. An exit interview was conducted. A copy of this 809-Report, appeals rights, and 809-D Page were given to the facility.the state’s words, verbatim · CDSS document, Aug 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Sep 30, 2026

1569.652(c) Termination of admission agreement...A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual... within 15 days after the personal property is removed. This requirement was not met as evidence by: based on interviews and file review, the licensee did not provide a refund to R1 in a timely manner. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: Facility staff agrees to conduct a board and care fee/refund audit review for all residents. Facility staff agrees to update itemized care service fee document by POC date: September 30, 2026. Audit documents and itemized care service fee document shall be emailed to LPA Martinez by POC date: September 30, 2026 by 5:00 PM.

Allegation investigated: Resident sustained multiple falls due to staff neglect.

On August 05, 2026, at 1:00 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Elvyra Abare during today’s visit, and explained the purpose of today's visit. Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and toured the facility. After conducting confidential interviews with relevant parties, it was learned resident 1 (R1) did not sustain multiple falls. In addition, the investigation revealed R1 uses durable medical equipment (DME) to ambulate independently throughout the facility. When interviewed, R1 indicated they are able to ambulate with the use of DME, and did not fall while attempting to sit on a chair located at the dinning room. R1 reported while attempting to sit on the chair, they need assistance. R1 reported they received assistance from facility staff. LPA Martinez also interviewed witness 1 (W1), and W1 reported that facility staff members are providing appropriate care to R1. Continued... Unsubstantiated Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 5, 2026 · control 27-AS-20260721113433

Allegation investigated: Facility is not kept in a clean sanitary condition. Facility is not adequately addressing insect infestation. facility does not maintain adequate food supply. facility administered incorrect medications to resident.

On July 30, 2026, at 12:00 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Elvyra Abare during today’s visit. Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and conducted facility tours. The facility was cited Maintenance and Operation 87303 (a) on April 10, 2026, and on May 04, 2026, for the following allegations, pest infestation and facility is not kept sanitary. The facility complied with the April 10, 2026, and May 04, 2026 plan of corrections (POC). The facility continues to follow up on the cleaning plan of correction and pest control plan of correction. Also, Clark Pest Control conducts monthly pest visits and treatments. Additionally, LPA Martinez toured the facility with staff 1 (S1) on July 30, 2026, and LPA Martinez observed that the facility was sanitary. During the July 30, 2026, tour, LPA Martinez did not observe any pest. Continued... Unsubstantiated Moreover, during the July 30, 2026, facility tour, LPA Martinez inspected the facility kitchen with staff 1. LPA Martinez observed that the facility had an adequate food supply. LPA Martinez has also been receiving weekly menus and food supply invoices since June 02, 2026. The facility staff has continued to follow up with ensuring that the facility has an adequate food supply. LPA Martinez reviewed resident 1's (R1) October 2025, medication administration record (MAR) and medication notes. The MAR did not indicate that there were any medication errors. R1's medication administration notes did indicate that there were any medication errors. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 27-AS-20251001144234

Type of visit: Case Management - Other

On July 09, 2026, at 1:00 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Sulma Lopez arrived at facility unannounced to conduct a case management visit. LPAs met with Ylvyra Abare and explained the purpose of the visit. The purpose of the visit is in response to the September 03, 2025, inspection visit. The following deficiencies will be cited today; as result of learned decencies from the September 03, 2025, inspection visit: 1569.695(d) Emergency Plans and 87405 (d)(4) Administrator - Qualifications and Duties. The deficiencies can be found on the 809D-Page. An exit interview was conducted, and a copy of the 809 report, 809-D Page, and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(d) · Plan of correction due date: Jul 31, 2026

1569.695(d) Emergency Plan: A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirment was not met as evidence by: based file review and interviews the Licensee did not ensure that facility staff was updating the emergency plan as necessary. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: Facility staff agrees review the emgency plan and make any neccessary updates by POC date: 07/31/2026. Facility staff agrees to email reviewed emergency plan by POC date 07/31/2026 by 5:00 PM to LPA Martinez

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(4) · Plan of correction due date: Jul 31, 2026

87405(d)(4) Administrator-Qualifications and Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.When applicable, the ability to direct the work of others. This requirment was not met as evidence by: based on interviews, file review, and observation, the Licensee did not esnure the Administrator had the ability to direct the work of others. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: The facility staff agrees to conducte a mock emergency drill for all staff. The mock emergency drill will include delegation of emergency tasks and relocation tasks by poc date poc date 07/31/2026.

Allegation investigated: Staff do not ensure resident's medication is being administered.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on June 04, 2026 at 9:15 AM to deliver complaint findings, LPA Martinez met with Ylvyra Abare, and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews, inspected medication room, and reviewed medication administration records (MAR). LPA Martinez interviewed five staff and interviewed five residents. Five out of five staff reported that medication is being administered to residents in a timely manner. In addition, staff have reported that they ensure that residents have ingested their medication. Five out of five residents reported they had no concerns about medication administration, and are receiving their medication timely. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 4, 2026 · control 27-AS-20260403120150

Allegation investigated: Staff mismanage resident's medication. Staff do not ensure medication is kept in its original container. Staff falsify medication administration records. Staff yells at resident

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on June 04, 2026, at 9:15 AM to deliver complaint findings, LPA Martinez met with Ylvyra Abare, and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews, inspected medication room, and reviewed medication administration records (MAR). Based on interviews Staff 1 (S1) does not administer medication, and S1 reported they do not administer medication. S1 also, reported they did not administer ear drop medication into resident's 1 (R1) eyes. LPA Martinez interviewed resident 1 (R1), and R1 reported that facility staff do not administer ear drops into their ears. R1 also reported that staff do administer any medicine into their eyes. LPA Martinez reviewed R1's MAR, and the MAR does not show that R1' has an open order for ear drops. During medication room inspections, LPA Martinez observed that medication were kept in their original container. LPA Martinez reviewed six medication administration records and did not observe any discrepancies. Continued... Unsubstantiated Five out of five residents reported that no staff has mistreated them or yelled at them. Five out five staff reported that they have never yelled at a resident. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 27-AS-20260515111823

Allegation investigated: Staff does not ensure that resident's medications are secured.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on June 04, 2026, at 9:15 AM to deliver complaint findings, LPA Martinez met with Ylvyra Abare, and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez inspected the medication room, Inspected residents' medication lock boxes, and conducted interviews. During this investigation, LPA Martinez and LPM King inspected locked safe medication boxes in resident rooms. The medication storage inspections were conducted on May 04, 2026, and June 02, 2026. On both inspections, residents had their medication secured in a locked safe box. LPA Martinez and LPM King observed that residents kept their medication secured and in a locked safe box. Resident are also informed by the facility that medication has to be kept in their secured lock safe box at all times. Continued... Unsubstantiated Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 27-AS-20260406194252

Allegation investigated: Staff do not answer residents calls for assistance timely

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on June 04, 2026, at 9:15 AM to deliver complaint findings, LPA Martinez met with Ylvyra Abare, and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews, conducted call button inspections, and reviewed call button logs. LPA Martinez reviewed ten resident call pendent logs from the period of May 15, 2026 to May 18, 2026. The call pendent logs showed that there were twenty-five call pendents that were not responded to within five minuets. The longest wait time was fifty-six minuets and seventeen seconds and the shortest wait time was five minuets and thirty seconds. Moreover, on May 04, 2026, LPA Martinez pressed a call pendent in the memory care unit. Facility care staff did not respond to call pendent because the call pendent alert system volume was turned off. During this call pendent inspection, LPA Martinez requested that the memory call pendent system volume be turned on. Facility staff 1 (S1) ensured that memory call pendent system volume was turned on. Continued... Substantiated As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 27-AS-20260507101026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 15, 2026

Basic Services 87464(f)(1): Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: based on file reviews, interviews, observation, the licensee did ensure staff were meeting residents in care needs and providing ADL assistance when needed. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Facility has implemented new pagers, and Med-Techs now supervise call pendent calls. In-training service was conducted on May 04, 2026 and June 04, 2026. Staff agrees to email LPA Martinez call pendent call procedures and in-service training documentation by June 15, 2026 5:00PM.

Allegation investigated: Facility is not serving meals in a timely manner.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on June 02, 2026, at 9:15 AM to deliver complaint findings, LPA Martinez met with Jeannette Elliott, and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews, conducted food supply inspections, and observed prepared meals, and observed meals being served. Based on interviews it was learned that the facility table service procedures were causing disorganization in regards to serving meal plates and attending residents in care during mealtimes. It was also learned that there were limited kitchen staff members during mealtimes due to scheduled rest breaks. The facility has implemented new table service procedures and work schedules to improve meal service. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility. Substantiatedthe state’s words, verbatim · CDSS document, Jun 2, 2026 · control 27-AS-20260504120120

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(18) · Plan of correction due date: Jun 2, 2026

General Food Service Requirements 87555(b)(18): Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met as evidence by: based on interviews, file reviews, observation, the Licensee did not ensure food service personnel were meeting the needs of the residents and serving meals timely.the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: Facility has hired five servers and created a new time schedule for serving meals. Has implemented ongoing training for servers. Has implemented new table service procedures. Facility staff agrees to conduct daily serving audit, and email LPA Martinez audit findings weekly until September 1, 2026.

Allegation investigated: Meals provided are not of good quality.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on June 02, 2026, at 9:15 AM to deliver complaint findings, LPA Martinez met with Jeannette Elliott, and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews, conducted food supply inspections, and observed prepared meals, and observed meals being served. Based on interviews it was learned that frozen food products were mostly being used to prepare meals. Other information gathered from interviews indicated the meals being served were tasteless and of poor quality. The investigation also revealed some meals were over cooked while other meals were under cooked. LPA Martinez was also informed that facility has made changes to the food supply. The facility is purchasing less frozen foods, and incorporating fresh food ingredients into their daily menu. Additionally more meals are also being made from scratch. Continued... Substantiated As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 27-AS-20260312082614

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Jun 16, 2026

87555(b)(8)General Food Service Requirements: All food shall be of good quality. This requirement was not met as evidence by, based on observation, file review, and interviews, the Licensee did not ensure meals being served were of good quality. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2026

Plan of correction: Facility has hired two new chefs and culinary manager. Also hired five servers. The facility is buying less frozen food. Facility staff agrees to email LPA Martinez July-Aug-Sept menus and food supply invoices for July-Aug-September.

Allegation investigated: Facility is not conducting fire drills.

On May 04, 2026, at 8:30 AM, Licensing Program Analyst (LPA) Avelina Martinez and Licensing Program Mangager (LPM) Liza King conducted an unannounced facility visit to initiate a complaint investigation and deliver findings for the above allegation LPA Martinez met with Ylvyra Abare and explained the purpose of today’s visit. During today's facility visit, LPA Martinez and LPM King conducted interviews and obtained facility records. It was learned that fire drills were not being conducted as required. The fire drills are being conducted during all staff meetings, and are not being conducted at each shift. In addition, based on interviews it was learned that residents in care are not invited to partcipate in emergency drills. Continued... Substantiated Resident should be provided the opportunity to participate in emergency drills. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Emergency Plans deficiency is cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility.the state’s words, verbatim · CDSS document, May 4, 2026 · control 27-AS-20260504120120

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.695(c) · Plan of correction due date: May 5, 2026

1569.695(c) Emergency Plans:A facility shall conduct a drill at least quarterly for each shift...An actual evacuation of residents is not required during a drill...While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. This requirement was not met as evidence by: based on interviews and file reviews. The facility did not conduct emergency drills at each shift and did not provide an opportunity for residents to participate in emergency drills, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: Facility staff agrees to conduct an emergency drill at each shift by 05/05/2026. Facility staff agrees to email LPA Martinez emergency drill documentation by 05/06/2026 by 5:00 PM.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Manager (LPM) Liza King and Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility to deliver complaint findings. LPA and LPM met with Elvyra Abare whom identified themselves as the newly appointed Executive Director. During todays visit verification of fingerprint and association was conducted to ensure the individual was cleared to be present and working in the facility. Current census 68 in Assisted Living and 28 in Memory Care, 2 residents on hospice throughout the building. For Admin changes, the RO requests the following documentation to be submitted by 05/06/26 · A letter from the licensee and/or Board appointing the individual as the Administrator · LIC308 · Copy of current Admin Cert · Any documentation that meets the education and/or experience requirements, if applicable · LIC 200 signed by the licensee or designee · LIC 500 to indicate the days/hours the administrator is in the facility · LIC 501 so that we can determine if the Admin meets the education/ experience requirement. cont. A tour of the facility was conducted. Residents in the memory care (MC) neighborhood appeared clean and well kept, breakfast service was concluding, then residents were engaged in a sing along followed by exercises. Five rooms were entered, 5/5 rooms contained personal care supplies. 1/5 rooms contained cleaning supplies; tide pods-this rooms door was propped open. Interview with a caregiver deemed the facility does not have a practice in place to determine which residents are allowed access to personal care supplies and which are not. Additionally, cleaning supplies were observed under the sink in an unlocked cabinet. A ladder and tool case with various tools were left unattended. Staff belongings including purses and backpacks were left accessible to residents. These practices present an immediate risk to residents in care. A discussion occurred with the Administrator whom acknowledged the issue. A review of staff training records revealed an inservice had occurred over the past 30days re: accessibility to cleaning solutions and toxins. On the MC patio a long metal rod was observed. A pull cord was pulled in the MC area. After not being addressed for several minutes LPM observed that the volume was muted on the device which alerts staff a pull cord has been pulled. Review of a second device showed the same volume setting. 4 resident files were reviewed. 1/4 documented the resident was not allowed access to personal supplies, additionally 1/4 documented lack of safety awareness and impulsivity and able to have access which may be contradictory. LPM recommends reviewing this documentation throughout the MC area and creating a plan to ensure those that would be at risk are protected and staff are knowledgeable. Diet orders were verified against the resident physician orders and notification to care staff which is posted in a conspicuous place for the staff to refer to with no concerns. Water temp was within regulatory range. No odor was present and the area appeared clean and well-kept, except for the refrigerator which should be wiped down. Recommendation is to establish a cleaning schedule for the communal and private refrigerators throughout the building. Communal bathrooms were clean. Observations were conducted on the Assisted Living (AL) side at lunchtime. Live music was being performed prior to lunch service. Water temp was within regulatory range. Eight rooms were entered and met regulatory requirements. No odor was present and the communal area appeared clean and well-kept, except for two communal refrigerators which should be wiped down. Recommendation is to establish a cleaning schedule for the communal and private refrigerators throughout the building. Communal bathrooms were clean. cont Observation in the kitchen area showed dead carcasses of bugs, guidance was provided in establishing a routine cleaning schedule behind appliances and corners of rooms. Additionally, garbage can lids on the exterior of the building are not being closed which attracts insects and rodents. Additionally, the following documentation was reviewed and are of no concern at this time · Backflow Testing conducted 07/01/2025 · Ansul Semi Annual Inspection 10/17/2025 · Fire Alarm Annual Inspection and Testing 10/17/2025 · Annual Sprinkler Testing 10/17/2025 · Elevator Inspection 10/28/2025 · Disaster Plan inc Earthquake, Relocation, Communication, Pandemic, Power Failure, Active Shooter, Bomb Threats, Infection Control Plan and LIC610. Provided a new Administrator is present it is recommended a review of the above and documentation. The above information is not all inclusive of todays visit, this information and these observations are in addition to those being cited on complaint visit reports dated today. Citations are being issued as a result of these observations and findings and an exit interview was conducted with Elvyra Abare. Appeal rights were provided.the state’s words, verbatim · CDSS document, May 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(b) · Plan of correction due date: May 4, 2026

(b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This was not met as evidenced by cleaning supplies being accessible to residents in care which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: Immediate dangers were removed or fixed during todays visit. The Admin will conduct training with all staff within 2 weeks.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: May 18, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. This was not met as evinces by dead bug carcuses being observed, communnal refridgerators not being clean and did not have a freezer thermometer, trashcan lids being openthe state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: The Admin will conduct a training of Supervisors and staff within 2 weeks then conduct unannounced checks.

Allegation investigated: ) Questionable Death 2) Staff did not seek timely medical care for residents in care 3) Staff did not prepare food in a safe and healthful manner

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the ACC Maple Tree Village RCFE on 4/16/26 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with staff member, Brittany Yamada and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA Gould obtained records for all residents who had passed away while residing at the facility from March to June 2025 as no individuals were identified in the complaint. The department obtained death certificates and death reports for each resident identified. Death certificates obtained indicated no suspicious causes of death. Report Continued on LIC 9099-C Unsubstantiated LPA conducted interviews with eight residents. All residents interviewed denied any delays in staff responses and denied any delays in the facility seeking timely medical care. All residents interviewed indicated medications are administered timely. All residents interviewed expressed to LPA that staff are quick to respond to call pendants in cases of falls or other requests for assistance. Residents interviewed expressed positive views of food being provided. Residents interviewed identified the variety of foods prepared as a positive experience. LPA conducted a walk through of the kitchen and all food storage areas. LPA observed the kitchen to be clean and well organized. LPA observed no evidence of pests in the kitchen. LPA conducted interviews with four kitchen staff who all provided statements the kitchen staff are working hard to ensure the kitchen is clean and food is prepared in a safe and healthful manner. All staff members identified the kitchen as a safe and clean place for food preparation and service. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Questionable Death, Personal rights and food service are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility. The Department has investigated the complaint alleging Physical plant. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 27-AS-20250609113259

Allegation investigated: Staff did not ensure the facility was free from of pests

Licensing Program Analyst (LPA) Arielle Pascua arrived at the facility unannounced on 04/08/2026, at 2:45pm to deliver complaint findings. LPA Pascua met with Facility Representative, Brittany Yamada and explained the purpose of the visit. Throughout the course of the investigation, LPA Martinez conducted interviews, inspected the facility plant, and reviewed facility records. Based on LPA Martinez's March 20, 2026, physical plant tour, it was determined that the facility is not free from pests. During the March 20, 2026, facility tour, LPA Martinez observed an accumulation of dead insect, arachnids, and cockroaches through the facility. Additionally, LPA Martinez observed a buildup of dead pests on glue traps. LPA Martinez also observed one fire extinguisher cabinet to be unsanitary. The top of the cabinet had dust buildup and dead pests. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility. Substantiatedthe state’s words, verbatim · CDSS document, Apr 8, 2026 · control 27-AS-20260316124213

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 10, 2026

87303 Maintenance and Operation(a): The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation and interviews, the Licensee did not ensure that the facility was free from pests and sanitary. This posed a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: Facility Representative stated that cleaning logs have been implemented as well as pest control has been vendored. A copy of services rendered will be sent to the LPA for the next 3 months and copies of cleaning logs along with pictures will be sent to the LPA by POC date.

Allegation investigated: Physical Pant: Staff did not ensure the facility was free of pests

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to ACC Maple Tree Village RCFE on 1/8/26 at 9:15am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Administrator, Yesenia Jones and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA condcuted a walkthrough with the maintenance director of kitchen and food storage areas. When inspecting the kitchen dry storage area, LPA observed grains of rice on the floor and pieces of uncooked pasta unsealed on storage shelves. LPA moved a box and observed a rodent feces on the shelves next to sealed food items. LPA instructed kitchen staff to pull all items and deep clean the dry storage area. While the facility has continued services with pest control and even change pest control services the kitchen staff are not ensuring the kitchen area is being appopriatly cleaned and food stored to ensure pests are not attracted to the kitchen. Report continued on LIC 9099-C. Substantiated The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Physical Plant is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 27-AS-20251015162429

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jan 12, 2026

General Food Service Requirements: All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by LPA observations of rodent droppings in the kitchen dry storage area which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 8, 2026

Plan of correction: The administrator has agreed to develop an updated kitchen cleaning plan that address a more detailed daily, weekly and monthly cleaning plan for the kitchen and will assign specific tasks to specific kitchen staff to ensure the kitchen is clean and does not continue to attract rodents in the kitchen.

Allegation investigated: ) Licensee does not ensure facility is maintained in good repair. 2) Staff do not ensure that residents are adequately fed while in care.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the ACC Maple Tree Village RCFE on 1/8/26 at 9:15am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Administrator, Yesenia Jones and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA Gould conducted interview with eights (8) residents, two (2) family members and two (2) staff members. Of the residents interviewed seven of the eight residents denied the facility ever running out of food during meals. Report continued on LIC 9099-C Unsubstantiated One resident interviewed provided statements that the facility ran out of one main course but the facility had alternative food options such as a second main course prepared daily and an alternative menu offered daily including hot and cold sandwiches, salads and other options available at lunch or dinner. Staff members interviewed denied ever running out of food to serve residents. LPA reached out to and conducted interview with co-complainant but could not verify their allegations. LPA also conducted kitchen walk through, observed fridge temperatures and observed documented readings of fridge temperatures that corresponded with LPA observations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Physical Plant and Food Services are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 27-AS-20250930163954

Type of visit: Case Management - Health Checks

On 12/17/25 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Health Check following the repopulation of the Memory care of the facility following renovations from a previously reported flooding event. LPA observed appropriate staff members present in the memory care. All residents have returned to the facility and all rooms are fully furnished and able to meet the needs of residents and meets all licensing requirements. LPA observed all medications for residents present. LPA observed facility staff conducting activities and resident participation. No deficiencies were observed or cited during today's inspection.the state’s words, verbatim · CDSS document, Dec 17, 2025

Type of visit: Case Management - Other

On 12/4/25 at 3:10pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced inspection to ensure the memory care area of the facility is cleared to be repopulated. LPA Gould met with administrator Yesenia Jones who provided LPA with a finalized inspection by the the city of Sacramento indicating the facility area has passed inspection and is ready to be repopulated by residents. LPA met with administrator and discussed the timeline for the next two weeks including moving furniture, deep cleaning, returning resident belongings, moving major furniture, medications and final moving of all residents back to the facility. As LPA observed there is a great amount of furniture to be moved, an inspection/evaluation was not possible at the time of inspection. A follow up visit corresponding to the agreed timelines for repopulation will be conducted. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Required - 1 Year

On 11/14/25 at 9:15am Licensing Program Analyst (LPA) Kevin Gould arrived at ACC Maple Tree Village for the purpose of conducting a required 1 year annual inspection. LPA met with administrator, Yesenia Jones and together conducted a tour of the facility. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. The facility is divided into four communities but all in one building. There is a separate memory care section of the facility. All memory care residents are currently relocated to an alterative location due to construction/renovation from a water damage event. LPA measured the water temperature, temperature measured at 110 to 114 degrees F at various locations in the facility which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA was able to review 9 resident files and 9 staff files. All resident and staff files were complete and well organized. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 14, 2025

Allegation investigated: ) Staff did not ensure the fridge is not in disrepair 2) Staff are serving residents expired food

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the ACC Maple Tree Village RCFE on 10/23/25 at 9:20am to inform the facility of the complaint allegations and to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Administrator, Yesenia Jones and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA conducted a thorough inspection of the kitchen with a representative from Sacramento County Environmental Health. LPA and County representative observed all fridges and freezers present at the facility to be operating and maintaining a temperature required by department regulations. LPA and county inspected the food supply and observed all food items to be labeled in accordance with regulations and LPA and county representative did not observe any spoiled, expired or contaminated food items present during the inspection. Report Continued on LIC 9099-C. Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Food service are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 27-AS-20251015162429

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: ) Staff did not ensure residents personal items were safely secured 2) Staff damaged residents personal property 3) Staff do not ensure residents are spoken to in an appropriate manner 4) Staff do not ensure resident receives assistance with dental hygiene

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the ACC Maple Tree Village RCFE on 10/23/25 at 9:20am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Administrator, Yesenia Jones and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA Gould condeucted interview with R1 who was alert orienatded and able to respond to LPA questions. Per interview R1 denied needing assistance with dental hygiene. Per R1's needs and services plan, R1 did not have full assist with dental hygiene, R1 was listed as needing prompting and setting up toothbrush and toothpaste and R1 was documetned as able to complete this ADL. R1 denied the allegation of being spoken to in an inappropriate manner. R1 only provided positive statemets regarding staff interactions and identified as being treated with kindness and respect. Report Continued on LIC 9099-C. Unsubstantiated The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home. Regarding allegations that personal items were not secured. LPA conducted a review of R1's documented inventory and observed the inventory was declined at admission and was never updated with any items of personal value documented including perfume. LPA reviewed the Theft/Loss policy binder and observed the perfume to be documented appropriately per Title 22 regulations. As no items have been documented as part of the resident inventory, LPA was unable to obtain any evidence the item as described was present at the facility prior to being reported missing to the administrator. Additionally, R1 denied any clothing items were damaged by ACC staff. LPA and R1 looked at a few clothing items and LPA only observed R1's name documented in tags and on interior clothing identifying R1's clothing. Staff interviewed denied making any statements or remarks to any residents Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 27-AS-20250218132220

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f) · Plan of correction due date: Oct 31, 2025

Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by observed delays in responses to pressed resident pendant which poses a potential health, safety and personal right srisk to residents in carethe state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: Facility has agreed to conduct weekly audits for one month and provide those audits to the department each Friday. Any delays will be identified and provide information as to what steps the facility has taken in regards to each individual incident.

Allegation investigated: Food Service: Food items are not being stored as required by regulations

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at ACC Maple Tree Village RCFE on 10/8/25 at 9:15am to inform the licensee of complaint allegation mentioned above and to deliver findings. Based on LPA observations during the investigation process, the allegations are substantiated. LPA conducted a walk through of the kitchen, inspected freezer and refridgerator and dry goods storage. LPA observed expired food items in the fridge. LPA observed expired and undated/unlabeled items in dry storage. LPA also observed boxed food items being stored on the floor of the freezer. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Food Service is substantiated. Substantiated The following deficiency is cited per California Code of Regulations, TITLE 22. An immediate civil penalty will be issued during today's inspection. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 27-AS-20251001144234

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(9) · Plan of correction due date: Oct 9, 2025

Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.This requirement was not met as evidenced by LPA observations of food being stored on the floor, expired items located in the fridge and dry storage, unlabled items being stored in dry storage containers. and several other dry storage items being expired per the lable wich poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: Facility has agreed to immediately schedule a consultation from a qualified person and share the documetented results of the consulation.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kevin Gould conducted Case Management deficiencies inspection to address personnel requirements observed by LPA during today's inspection. LPA Gould last met with a head chef/kitchen manager in April 2025. on all subsequent visits and inspections the facility has been without a full-time employee, qualified by formal training or experience to be responsible for the operation of the food service as the facility is licensed with a capacity greater than 50 residents. In the intervening months, LPA has observed at least two violations of food services regulations including unsanitary floors and surfaces, improper food storage, retention of expired food items, improper labeling of food storage. Per the California Code of Regulations, Title 22, the department has determine the facility is not in compliance with the above regulation and a deficiency was issued during today's inspection. Exit interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Oct 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(17) · Plan of correction due date: Oct 24, 2025

General Food Service Requirements: In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist , a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: Facility has agreed to provide documentation of efforts to obtain/hire a new kitchen manager including advertisements ans job postings. Facility has also agreed to immediately schedule a consultation from a qualified person and share the documetented results of the consulation.

Type of visit: Case Management - Deficiencies

On 9/3/25 at 2:45pm, Licensing Program Analyst (LPA) Kevin Gould made an unannounced case management inspection to ACC Maple Tree Village to address deficiencies observed by the department in relation to the emergency relocation of facility residents to unforeseen flooding/sewage issues in the facility memory care section. LPA reviewed the facility emergency disaster plan and observed it is in need up updating to reflect current circumstances and availability for resident relocation at identified locations and specified agreements. LPA observed all documented agreements dated from 2019 and under the circumstances of the relocation were unable to accommodate the number of residents required to be relocated. The department has concluded the facility Emergency disaster plan for relocation of residents was not sufficient to meet the relocation needs of residents. Additionally, the department has concluded based on management interaction with facility staff and representatives that the current administrator's knowledge of and ability to implement the facility emergency disaster plan was insufficient. This is evidenced by the facility's lack of a identified viable relocation site and delays in resident transportation to the relocation site. Per the California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. Exit interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87212(b)(2)(E) · Plan of correction due date: Sep 4, 2025

Emergency Disaster Plan: Relocation sites which are equipped to provide safe temporary accommodations for residents. This requirement is not met as evidenced by residents were not relocated to identified sites and department staff provided significant assistance to facility in identifying and arranging relocation of residents and arranging for temporary accommodations which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Facility will update their emergency disaster plan including identified relocation sites and ensure all information in the emergency disaster plan and emergency disaster manual (Binder) is updated at least annually or whenever it is determined an identified relocation site will no longer be a viable option for relocation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2) · Plan of correction due date: Sep 4, 2025

Administrator - Qualifications and Duties: Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by facility's inability to adhere to their emergency disaster plan and complete the relocation to an identified location or viable alternative as part of the emergency disaster plan.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Facility will provide a written plan that will become part of the emergency disaster plan going forward identifying backup staff members to take over identified emergency roles when those staff members are unavailable and or unable to respond to an emergency. The written plan will identify the staff and training to be provided to ensure adequate responses to an emergency.

Type of visit: Case Management - Deficiencies

On 9/3/25 at 2:45pm, Licensing Program Analyst (LPA) Kevin Gould made an unannounced case management inspection to ACC Maple Tree Village to address deficiencies observed by the department in relation to the emergency relocation of facility residents to unforeseen flooding/sewage issues in the facility memory care section. LPA reviewed the facility emergency disaster plan and observed it is in need up updating to reflect current circumstances and availability for resident relocation at identified locations and specified agreements. LPA observed all documented agreements dated from 2019 and under the circumstances of the relocation were unable to accommodate the number of residents required to be relocated. The department has concluded the facility Emergency disaster plan for relocation of residents was not sufficient to meet the relocation needs of residents. Additionally, the department has concluded based on management interaction with facility staff and representatives that the current administrator's knowledge of and ability to implement the facility emergency disaster plan was insufficient. This is evidenced by the facility's lack of a identified viable relocation site and delays in resident transportation to the relocation site. Per the California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. Exit interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87212(b)(2)(E) · Plan of correction due date: Sep 4, 2025

Emergency Disaster Plan: Relocation sites which are equipped to provide safe temporary accommodations for residents. This requirement is not met as evidenced by residents were not relocated to identified sites and department staff provided significant assistance to facility in identifying and arranging relocation of residents and arranging for temporary accommodations which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Facility will update their emergency disaster plan including identified relocation sites and ensure all information in the emergency disaster plan and emergency disaster manual (Binder) is updated at least annually or whenever it is determined an identified relocation site will no longer be a viable option for relocation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2) · Plan of correction due date: Sep 4, 2025

Administrator - Qualifications and Duties: Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by facility's inability to adhere to their emergency disaster plan and complete the relocation to an identified location or viable alternative as part of the emergency disaster plan.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Facility will provide a written plan that will become part of the emergency disaster plan going forward identifying backup staff members to take over identified emergency roles when those staff members are unavailable and or unable to respond to an emergency. The written plan will identify the staff and training to be provided to ensure adequate responses to an emergency.

Allegation investigated: Staff do not ensure facility is free from pests

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at ACC Maple Tree Village RCFE on 7/23/25 at 1:30pm to inform the licensee of complaint allegation mentioned above. During this investigation LPA Gould interviewed S1, S2 and S3 (See confidential name list LIC-811 dated 7/23/25). Based on the interviews conducted during the investigation process and documetnation obtained and LPAs own observations, LPA Gould was unable to corroborate the allegations. LPA conducted a walkthrough of the facility and Memory Care area. LPA observed several insect baits and traps to manange pests that may infiltrate the facility. Additionally, LPA observed the facility has routine pest control conducted monthly and documetnation shows facility is addressing pests on an a continual basis with regular inspections and addressing any pests noted during inspections. Report Continued on LIC 9099-C. Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of physical plant are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Food Service is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 27-AS-20250715090728

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Aug 18, 2025

General Food Service Requirements: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by LPA observations of dirty kitchen floor, undated and unsecured items to prevent contamination, expired foods in storage and walk in freezer with a high temperature of 5 degrees F. which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: Facility will provide a written plan of corrections including the use of a consultant, audits in a more frequent basis. Written plan will also include process and procedures for cleaning, storage and food preparation.

Allegation investigated: ) Staff do not ensure kitchen is kept in sanitary conditions. 2) Staff do not ensure expired food is properly discarded 3) Staff do not ensure perishable food is properly stored 4) Staff do not ensure food served to residents is of good quality 5) Staff do not follow food service sanitation practices which protect the food from contamination.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the ACC Maple Tree Village RCFE on 5/20/25 at 12:30pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with administrator, Yesenia Jones and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA Gould conducted two unannounced kitchen inspections and observed no violations of title 22 regulations in terms of food service or storage. LPA conducted interviews with three kitchen staff members, multiple residents eading lunch and the RP. All staff interviewed denied the allegations listed above. Residents informally interviewed during lunch had no objections to the quality of food provided, most informally questioned had positive outlook on the food being provided. Report Continued on LIC 9099-C. Unsubstantiated LPA conducted an interview with RP who did not provide many specifics other than food items being left out for extended periods of time and states there are picture to support the allegations. At the time of writing LPA still has yet to receive documentation from Reporting Party. LPA reviewed 3rd party audits and reviewed two recent reports from the auditing agency dated February 2025 and May 2025. Per the audit reports, the initial February audit the facility received a score of 87 percent with recommendations for deep cleaning in some areas but related to the allegations described. The audit found no errors or deficiencies with food storage/preparation. The second audit dated May 2025 the kitchen received a score of 98 percent with all deep cleaning items addressed. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Food Service are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 20, 2025 · control 27-AS-20250328131444

Type of visit: Required - 1 Year

On 11/27/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at ACC Maple Tree Village for the purpose of conducting a required 1 year annual inspection. LPA met with staff Derek Gehrer, and together conducted a tour of the facility. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. The facility is divided into four communities but all in one building. There is a separate memory care section of the facility. LPA measured the water temperature, temperature measured at 110 to 114 degrees F at various locations in the facility which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA was able to review 15 resident files and 10 staff files. All resident and staff files were complete and well organized. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 27, 2024

Type of visit: Case Management - Other

On 4/24/24 at 9:45am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to gather additional information regarding an incident report received by the department on 4/15/24. LPA met with administrator Yesenia Jones. LPA met with Administrator and Resident Care Coordinator to gather additional information and documents regarding reported incidents. LPA obtained names, address and contact information for four (4) staff members. R1's physician report, fall history, and companion information. Termination letter for S1 and discipline letter for S2. LPA also obtained LIC 500. Exit interview was conducted with facility staff and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 24, 2024

Type of visit: Case Management - Incident

On 4/16/24 at 12:15pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to address concerns regarding an incident report received by the department on 4/15/24. LPA met with administrator Yesenia Jones and together discussed the reported incident. LPA conducted interviews with S1, S2 and conducted interviews with four (4) residents (see confidential names list, LIC 811 dated 4/16/24). LPA obtained the following records: Employment Application for S3, Notes from S1's conversation regarding suspected abuse by R3, declarations from S4, S5, and S6. LPA has obtained a preponderance of evidence to support S3 did in fact speak inappropriately to residents in care and did not treat residents with dignity and respect including not allowing a resident to get up from their wheel chair. LPA provided Administrator with copies of LIC 855 (Declaration Form) to be filled out by all staff members who provided written statements regarding suspected abuse by another staff member. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 17, 2024

Reporting Requirements: Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by statements obtained from S1 that a staff member had knowledge of inappropriate behavior by another staff member (cursing, rudeness) towards several residents in care that took place in February 2024 and was not reported to management or the department in a manner that meets regulations which poses an immediate health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2024

Plan of correction: Facility has conducted in service training on mandated reporting and documentation will be submitted to the department by 5:00pm on the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(1) · Plan of correction due date: Apr 17, 2024

Personal Rights of Residents in All Facilities: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by three declarations provided by three staff members who witnessed staff member act in an unprofessional manner and cursed and handled residents in a manner that did not treat residents with dignity and respect which poses an potential health safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2024

Plan of correction: Facility is scheduled to conduct in service training today on employee conduct at the facility and documentation will be submitted to the department by 5:00pm on the POC due date.

Type of visit: Required - 1 Year

On 11/29/23 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at ACC Maple Tree Village for the purpose of conducting a required 1 year annual inspection. Due to a computer error, LPA was unable to access the required 1 year annual selection and LPA was unable to utilize the annual inspection care tools. This report will substitute as the required annual inspection. LPA met with Administrator, Yesenia Jones and together conducted a tour of the facility. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. The facility is divided into four communities but all in one building. There is a separate memory care section of the facility. LPA measured the water temperature, temperature measured at 110 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA was able to review all resident files and were unable to review all staff files as part of the staff files are kept off site. LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 29, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(g) · Plan of correction due date: Dec 29, 2023

All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. LPA was unable to review all staff files including Health screening reports as they were stored off site and could not be provided in a timely manner witch poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 29, 2023

Plan of correction: LPA and Administrator discussed required documents identified in LIC 311F and Administrator agreed to the facility ensuring all documents identified in the LIC 311F are stored at the facility and will be available for licensing to review.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) arrived unannounced on 10/10/23 at 1:30p to obtain additional information regarding an SIR received 2/2/23. LPA met with Yesenia Jones, Administrator and stated the purpose of the visit. LPA reviewed with administrator the contents of the SIR. The administrator conducted an internal investigation where as the care staff was providing medication administration timely and resident was not refusing to take medication. Resident #1, was not experiencing adverse reaction, however, it was noted that R1 was actually not swallowing the medication and was discarding them once staff was not present (cheeking). The responsible parties found the medications in R1's clothing. Based on the information provided, this has not occurred before and precautions have been put into place to assist staff in ensuring medications are taken by residents or document any refusals. The facility conducted in-service to medication technicians to try to ensure residents are swallowing medications before leaving the area. The facility was deemed to not be at fault for medication error at this time. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held, A Copy of report given.the state’s words, verbatim · CDSS document, Oct 10, 2023