Maple Tree Care Home

Type of visit: Required - 1 Year

On 07/16/2026, Licensing Program Analyst (LPA) M Vega arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured the facility with facility Administrator (AD) - Irina Chernyakova. AD was notified of Licensing visit over the phone and was able to attend the visit. The facility was observed to be at a comfortable temperature, of 76 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed residents in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility. Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. A fire extinguisher was observed with a service date of 07/16/2026. All six private residents’ bedrooms were observed to be at comfortable temperatures. The bathroom’s water temperature was tested and recorded reading of 115.5 degrees F. Medications observed to be locked in a cabinet in the common area. LPA reviewed medication records appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the storage it the laundry room. An outdoor seating area was observed operational for residents in care. Continuation on LIC 809C Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate and up to date information for your facility. In an effort to maintain your facility file, please submit the most current and complete forms and/or information as identified below: Residential Care Facility for the Elderly (RCFE) LIC 308 Designation of Facility Responsibility LIC 309 Administrative Organization LIC 400 Affidavit Regarding Client/Resident Cash Resources LIC 402 Surety Bond LIC 500 Personnel Report LIC 610E Emergency And Disaster Plan For Residential Care Facilities For The Elderly LIC 9020 Register of Facility Clients/Residents Copy of current Liability Insurance Copy of current Administrator Certificate Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 07/30/2026 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. No deficiencies issued during this inspection. An exit interview was conducted with the Administrator (AD) - Irina Chernyakova. A copy of this report was given to Administrator whose signature on this form confirms receipt of these reports.the state’s words, verbatim · CDSS document, Jul 16, 2026

Type of visit: Required - 1 Year

On 07/01/2025, Licensing Program Analyst (LPA) M Vega arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured the facility with facility Administrator (AD) - Irina Chernyakova. AD was notified of Licensing visit over the phone and was able to attend the visit. The facility was observed to be at a comfortable temperature, of 77 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed residents in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility. Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. A fire extinguisher was observed with a service date of 08/19/2024. All six private residents’ bedrooms were observed to be at comfortable temperatures. The bathroom’s water temperature was tested and recorded reading of 116.2 degrees F. Medications observed to be locked in a cabinet in the common area. LPA reviewed medication records appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the storage it the laundry room. An outdoor seating area was observed operational for residents in car Continuation on LIC 809C Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): LIC 308 Designation of Facility Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly LIC 9020 Register of Facility Clients/Residents Copy of current Liability Insurance Copy of current Administrator Certificate Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 07/11/2025 As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed. No deficiencies issued during this inspection. An exit interview was conducted with the AD A copy of this report was given to AD whose signature on this form confirm receipt of these reports.the state’s words, verbatim · CDSS document, Jul 1, 2025

Allegation investigated: Staff retaliated against the resident for making a complaint

On 08/13/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Irina Chernyakova and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care. Once the tour was complete, LPA discussed the findings with the AD. Allegation: Staff retaliated against the resident for making a complaint. Based on records review reporting party wish to stay and remained anonymous. 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, therefore the allegation is unsubstantiated. Report continues on attached LIC 9099-A Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 13, 2024 · control 24-AS-20240415082920

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87202(a) · Plan of correction due date: Aug 14, 2024

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This was not observed as evidenced by: The resident room fire exit sliding patio door was blocked and unable to open half way by a screw placed by a facility staff, this poses potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2024

Plan of correction: Following POC, the facility staff reviewed title 22 regulations and corrected the deficiency the same day.

Allegation investigated: Staff do not keep facility floors clean and sanitary Staff do not administer resident’s medications as prescribed

On 07/18/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Irina Chernyakova and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care. Allegation: Staff do not keep facility floors clean and sanitary. Based of observations on 5/08/24 and records review, and staff interview floors get cleaned daily. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Allegation: Staff do not administer resident's medications as prescribed. Based on file review and observation during the facility visit on 5/08/24 residents receive medications as prescribed. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted, report signed and copy of this report provided to the Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 18, 2024 · control 24-AS-20240501130807

Allegation investigated: Staff handled resident in a rough manner. Staff yelled at resident. Staff did not follow resident's modified diet.

On 07/18/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Irina Chernyakova and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care. Allegation: Staff handled resident in a rough manner. Based on interviews, observations, no residents reported being handled in rough manner. 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, therefore the allegation is Unsubstantiated. Allegation: Staff yelled at resident. Based on observations, interviews no guest or residents observed staff yell at resident. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Report continues on attached LIC9099-C Unsubstantiated Allegation: Staff did not follow resident's modified diet. Based of interviews and records review the facility followed residents diet. 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, therefore the allegation is Unsubstantiated. Exit interview conducted, report signed and copy of this report provided to Administrator for facility records.the state’s words, verbatim · CDSS document, Jul 18, 2024 · control 24-AS-20240409143113

Allegation investigated: Staff did not prevent resident from having exposure to a hazardous substance. Staff did not ensure that resident was fed.

On 07/18/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Irina Chrnyakova and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care. Once the tour was complete, LPA discussed the findings with the AD. Allegation: Staff did not prevent resident from having exposure to a hazardous substance. Based of interviews and observations no hazardous substances available to residents observed. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Allegation: Staff did not ensure that resident was fed. Based on file review and observation during the facility visit on 5/08/24 no concerns observed. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted, report signed and copy of this report provided to the Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 18, 2024 · control 24-AS-20240506123424

Type of visit: Required - 1 Year

On 07/18/2024, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured the facility with facility staff Iryna Vasylieva. Administrator (AD) was notified of Licensing visit over the phone and was able to attend the visit. The facility was observed to be at a comfortable temperature, of 73 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. LPA observed some residents in common area, others in their rooms resting. Department phone number and infection prevention information signs were posted thought the facility. Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. A fire extinguisher was observed with a service date of 06/19/2025. All six private residents’ bedrooms were observed to be at comfortable temperatures. The bathroom’s water temperature was tested and recorded reading of 112 degrees F. Medications observed to be locked in a cabinet in the common area. LPA reviewed medication records appears to be administered properly. Cleaning supplies were observed to be in a locked cabinet in the storage it the laundry room. An outdoor seating area was observed operational for residents in care. LPA reviewed staff and residents’ files. No deficiencies were observed and cited during this visit. Exit interview conducted. A report was signed, and a copy of this report was provided for facility records.the state’s words, verbatim · CDSS document, Jul 18, 2024

Allegation investigated: Staff removed resident's bed rails without proper authorization

On 05/10/2024, Licensing Program Analyst (LPA) V. Gorban visited the facility to deliver findings. During this visit LPA met with facility Administrator (AD) Irina Chrnyakova and stated the purpose of the visit. During this visit LPA toured the facility inside and out and observed residents in care. Once the tour was complete, LPA discussed the findings with the AD. Allegation: Staff removed resident's bed rails without proper authorization. Based of interviews and record reviews R1 does not have order to have rails or any other postural support on the bed. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted, report signed and copy of this report provided to the Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 10, 2024 · control 24-AS-20240509101316

Type of visit: Case Management - Incident

On 05/08/2024, Licensing Program Analysts (LPAs) V Gorban and B Miranda unannounced visited facility stated above to commence complaint investigation and complete a residents safety check. During this visit LPA met with facility staff Irina and Mercy. Administrator (AD) was notified of Licensing visit and was able to attend it. During the facility visit the facility staff shared with LPA that the fire department visited the facility on 4/14/2024 because of R1 call to FFD. When LPAs requested the incident report the Administrator did not have any reports on record to provide to Licensing. Also, during the facility tour on 5/08/24 LPA observed residents bed full rails raised up restricting resident mobility in rooms, 1, 2, 5, and 6. Full raised bed rails medical order was not provided by Administrator when requested. The deficiencies will follow on attached LIC809-Dthe state’s words, verbatim · CDSS document, May 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 10, 2024

87211 Reporting Requirements. (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified below. This was not observed as evidenced by: Facility failed to submit incident report for R1 that occurred on 4/14/24 in timely manner to Licensing, which posses potential safety risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: By plan of correction facility will ensure to review and follow title 22, reporting requirements and submit to LPA by email written statement by 05/10/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)5(b) · Plan of correction due date: May 14, 2024

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This was not observed as evidenced by: The facility failed to follow regulation by acquiring required documents and without proper documentation have residents full rails raised. That poses potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: The facility will provide requested files to Licensing department by POC due date (5/14/24) The facility will follow Licensing regulations and maintain residents bed rails as ordered by physician.