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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100403618
Report Date: 09/24/2025
Date Signed: 09/24/2025 01:10:55 PM

Document Has Been Signed on 09/24/2025 01:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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: 8DATE:
09/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator: ARCUINO, ELDADTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 9/24/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Kobi Walker. LPA was granted entry. 1 clients was present during inspection. The other 7 clients were attending Day Program. Administrator Camalah Kopacz (A1) was called but was not able to arrive for visit.

LPAs toured facility with S1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 37 degrees F. Cleaning chemicals was observed stored and locked under kitchen sink. Fire extinguisher was observed with a service date of: 7/1/25. Fire drill last completed on 07/28/25. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature tested at a range of 109.4 to 1116.7 degrees F. in 2 bathrooms. Outside of facility toured. Side gates were self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Medications were checked and observed kept locked in medication cart. LPA observed a resident’s pill/tablet on the floor of the kitchen and accessible to residents. Clients’ MARS was reviewed.

Carbon monoxide and smoke detectors were tested and observed to be operational. Samples clients’ file reviewed and was missing some required documents. All of the staff files were reviewed and observed to have all the required documents.



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

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 10/8/25: Lic 308, Lic 500, Lic 610D, and Lic 9020. LPA received a copy of current Administrator certificate. A copy of this report with appeal rights was provided to Staff, whose signature on this form confirms receipt of these report.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Jacques Leffall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
Document Has Been Signed on 09/24/2025 01:10 PM - It Cannot Be Edited


Created By: Jacques Leffall On 09/24/2025 at 12:42 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: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 tablet/pill was accessible to residents on facility floor which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2025
Plan of Correction
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Licensee agrees to have staff complete medication training and submit completion documents to CCLD by POC due date.
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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/24/2025 01:10 PM - It Cannot Be Edited


Created By: Jacques Leffall On 09/24/2025 at 12:42 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: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(2)
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (2) A copy of the Admission Agreement, containing basic and optional services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 5 residents is missing an Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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Licensee agrees to have the Resident's Admission Agreement completed and submit a copy to CCLD by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/24/2025 01:10 PM - It Cannot Be Edited


Created By: Jacques Leffall On 09/24/2025 at 12:42 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: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87469(a)
Advance Directives and Requests Regarding Resuscitative Measures
(a) Upon admission, a facility shall provide each resident, and representative or responsible person of each resident, with written information about the right to make decisions concerning medical care. This information shall include, but not be limited to, the Department's approved brochure entitled “Your Right To Make Decisions About Medical Treatment,” PUB 325, (3/12) and a copy of Sections 87469(b), (c) and (d) of the regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 5 residents are missing a consent for medical treatment form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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Licensee agees to have Consent for Medical treatment form completed and submit a copy to CCLD by POC due date.
Type B
Section Cited
CCR
87217(j)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview record review, the licensee did not comply with the section cited above in 1 out of 5 residents is missing the Safeguard for Property Values form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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LIcenseee agrees to complete the Safeguard for Property Values form and submit a copy to CCLD by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
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