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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100403618
Report Date: 11/21/2024
Date Signed: 11/26/2024 09:57:12 AM

Document Has Been Signed on 11/26/2024 09:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MAPLE AVENUE GUEST HOMEFACILITY NUMBER:
100403618
ADMINISTRATOR/
DIRECTOR:		ARCUINO, ELDADFACILITY TYPE:
740
ADDRESS:3341 N MAPLE AVETELEPHONE:
(559) 227-9722
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY: 14CENSUS: 11DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator Camalah Kopacz via telephone and staff Kobi WalkerTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 11/21/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and met with staff Kobi Walker (S1). Administrator Camalah Kopacz was called and unable to attend meeting. Administrator authorized and stated designee able to sign report. One resident was present upon LPA arrival in the common area. 9 residents arrived later during inspection.

LPA toured facility with S1. The facility was observed to be at a comfortable temperature and no passageway obstructions or fire hazards were observed inside or outside. Video camera with audio was observed in the living room and dining room.

Fire extinguisher was observed with a service date: 12/03/23. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 30 degrees F and freezer at -4 degrees F.

Cleaning supplies and chemicals stored and unlocked in laundry room. Dryer was operational during visit. Extra linens were observed in hall closet. All bedrooms were observed to have the required furnishings and with adequate lighting.

All bathrooms were toured and observed operational during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested at 105.3 degrees F in bathroom 1, 105.8 degrees F in bathroom 2, and 106.2 degree F in bathroom 3.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 09:57 AM - It Cannot Be Edited


Created By: Mai Yang On 11/21/2024 at 03:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAPLE AVENUE GUEST HOME
FACILITY NUMBER: 100403618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above when LPA observed chemicals stored in laundry room unlock and accessible to the residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Chemicals shall be inaccessible to all residents. Staff locked laundry room. POC cleared during visit.
Type A
Section Cited
CCR
87465(c)(2)
87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation and records reviewed, R1 and R2’s medications were not administered as directed by physician which poses an immediate health and safety risk for the person in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 11/22/24.

Licensee shall have all staff in-service trainings on medications regulations. Licensee will submit documentation of training topics including training date, training materials, training instructor name, and staff attendance rooster to the Fresno CCL office by 12/6/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 09:57 AM - It Cannot Be Edited


Created By: Mai Yang On 11/21/2024 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAPLE AVENUE GUEST HOME
FACILITY NUMBER: 100403618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(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 evidenced by:
Deficient Practice Statement
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Based on observation, spider webs were observed in corner of window in room 2 and 3. Spider webs was observed in corner ceiling wall in room 3. Binds were observed in disrepair in livingroom exit door and in residents’ bedroom window which poses/posed a potential health and safety risk for the person in care.
POC Due Date: 11/25/2024
Plan of Correction
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Proof of resident’s windows and room cleaned and free of spider and/or spider webs, and binds repaired in residents’ bedroom and in livingroom will be submitted to the Fresno CCL office by 11/25/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


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Document Has Been Signed on 11/26/2024 09:57 AM - It Cannot Be Edited


Created By: Mai Yang On 11/21/2024 at 03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MAPLE AVENUE GUEST HOME
FACILITY NUMBER: 100403618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1(a)(2) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when video cameras with audio was observed installed in the livingroom and dining room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Staff removed the video cameras with audio camera. POC cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MAPLE AVENUE GUEST HOME
FACILITY NUMBER: 100403618
VISIT DATE: 11/21/2024
NARRATIVE
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Outside of facility toured and observed to be free of debris. Adequate outdoor seatings available for residents. Medications were observed locked in cabinet in dining room. Sample of residents’ and staff files were reviewed. Smoke detectors and carbon monoxide were observed operational during visit.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 12/02/24. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610E, current liability insurance, and current Administrator certificate. Designee signed report. A copy of this report and appeal rights was provided to Administrator via email as requested.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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