Maple Tree Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Jessica Mendoza, Licensee. Contact information reviewed. Required postings were observed. The facility has a hospice waiver for two residents and there is one resident receiving hospice services. LPA/Licensee initiated a tour of the facility at 9:00 am and observed the following: Facility was a comfortable temperature and pathways were free from obstructions. All resident’s bedrooms have lighting & appropriate furnishings per regulation. Fire extinguishers were last inspected July 2025. Smoke detectors and the carbon monoxide detector were tested and operational during inspection. Auditory alarms installed at the doors that were tested and operational during the visit. Last Disaster drill was conducted on 8/10/25. Resident's bathrooms has required bath mat and grab bars. Water temperature in resident bathroom measured at 117.1 and 115.7 degrees F which is within the range allowed by regulation of 105 to 120 degrees F. Garage houses food pantry storage, laundry, incontinence care supplies, generator and emergency supply of water. Cleaning supplies are stored in a cabinet located in the garage and kitchen cabinet were inaccessible to residents in care. At least two days of perishable and seven days of non-perishable foods were available. Refrigerated food was found to be stored in a safe manner, some items were not labeled and dated per regulation, LPA had a conversation with the Licensee about the importance of labeling opened food with dates (technical advisory issued). Mediation and medication records were locked in the office by the hallway. Continued on LIC809C... Continued from LIC809... LPA initiated file review at 9:30 am. Four resident files including medical assessment and care plans. Three staff files were reviewed. Staff have required CPR/1st aid certificates. Training records were reviewed. Administrator Certificate for Jessica Mendoza #6072976740 expires on 11/20/2026. Medication and medication records were reviewed. Licensee agreed to submit updates of forms by 12/1/2025: Personnel Report (LIC500). No deficiencies cited during today's visit. Exit interview conducted with Licensee and a copy of report was given.the state’s words, verbatim · CDSS document, Nov 21, 2025

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: Post Licensing

Licensing Program Analyst (LPA) Cuadra arrive unannounced for the purpose of conducting Post-Licensing inspection visit and met with Administrator/Licensee Jessica Mendoza. LPA/Administrator toured the facility inside and outside. Facility is a one story building, with a total of 2 bedrooms, 2 shared bedrooms (room #2 & #3 and #5 & 6), 2 full bathrooms, office, laundry room located in the garage, kitchen, dining room, and living room as common areas. The facility was inspected and found to be clean and in good repair at the time of the inspection with all exits free from obstruction. Fire Extinguishers were charged and serviced as of June 2024. All auditory alarms, Smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the inspection. Hot water temperature measured at 102.7 and 100.2 degrees in resident's bathrooms which is not within regulation (technical advisory issued). Resident records, personnel records, medication and toxins were locked and inaccessible to resident's in care. Facility has first aid kit which was found to be appropriate during the Post-Licensing inspection. There is outdoor space for activities. All resident’s bedrooms have lighting & appropriate furnishings, and resident’s beds were outfitted with mattress pads as required by Title 22 Regulations. Required postings were observed. Last disaster drill conducted on 3/29/25. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated. Continue on LIC 809C... Continued from LIC809... File review initiated at 9:30am. Two staff files and one resident's file was reviewed. Resident has medical assessment and care plan on file, but care plan needs to be signed by the resident or their responsible party (technical violation issued). Staff have required CPR/1st aid certificate and initial training 40 hours complete. Administrator certificate for administrator Jessica Mendoza #6072976740 expires on 11/20/2026. Contact information reviewed. Medication and medication records reviewed. The Administrator agreed to submit updated copies of the following documents by 05/13/2025: LIC500- Personnel Report, LIC308- Designation of Responsibility, Infection Control Plan (review, update if needed), Emergency Disaster Plan (review, update if needed) and liability insurance. No deficiencies were cited during this Post-Licensing inspection. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, May 6, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analysts (LPA) Cuadra and Elias Magdaleno arrived announced to conduct a pre-licensing inspection and was greeted by Applicant, Jessica Mendoza. Facility currently does not have residents in care. Once obtained, Applicant will submit proof of required liability insurance. The facility consists of a single story residence with a total of 2 bedrooms, 2 shared bedrooms (room #2 & #3 and #5 & 6), 2 full bathrooms, office, laundry room located in the garage, kitchen, dining room, and living room as common areas. Hospice waiver for two residents. The facility received a fire clearance approval on 9/9/2024 by the Santa Rosa Fire Department for 6 non-ambulatory residents in rooms 1-4, which none may be bedridden. Administrator certificate for administrator Angelica Martinez #6001706740 expires on 4/10/2025. Contact information reviewed. At approximately 9:15am LPAs/Applicant toured the building and grounds. The facility was found to be at a comfortable temperature. All resident rooms #1-4 are furnished per regulation with bed, lamp, bedside table, dressers and chairs. Garage houses storage, laundry, incontinence care supplies and emergency supply of water. Cleaning supplies will be stored in a cabinet located in the garage and locked cabinet located in the hallway. Office has locked door and cabinet with a lock that will be used for medication and file storage. Back deck is connecting to shared bedroom #5 & 6 and bedroom # 4 allowing access to the backyard, they have auditory alarms installed at the doors that were tested and operational during the visit. Water temperatures read at: 111.5 and 109.9 degrees F which is within 105-120 F degrees regulation. All bathrooms have grab bars and skid mats available. Kitchen cabinet has locks installed for knives to be inaccessible to residents in care. Smoke and carbon monoxide detectors present and functioning. Two fire extinguishers serviced on June 2024. Call pendants were available for residents and they were tested and operational. LPAs observed all required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils. Night lights in hallway present. Activity calendar and supplies as well as sample of menu was observed. First aid kit present with all required items. Applicant has satisfied all requirements in accordance with Title 22 Regulations including Component III. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with the process of license. Pre-Licensing is now complete. Exit interview conducted with Applicant and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 24, 2025

Type of visit: Office

: Component II completion: Successful Facility Type: rcfe Application Type: initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Jessica Mendoza - applicant/licensee, Angelica Martinez - administrator Interview Method: microsoft teams On 01/10/25, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 10, 2025