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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 04/16/2026
Date Signed: 04/16/2026 03:27:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20250609113259
FACILITY NAME:ACC MAPLE TREE VILLAGEFACILITY NUMBER:
342700683
ADMINISTRATOR:YESENIA JONESFACILITY TYPE:
740
ADDRESS:18 KADO CTTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 88DATE:
04/16/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brittany Yamada TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
1) 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
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20250609113259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ACC MAPLE TREE VILLAGE
FACILITY NUMBER: 342700683
VISIT DATE: 04/16/2026
NARRATIVE
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20250609113259

FACILITY NAME:ACC MAPLE TREE VILLAGEFACILITY NUMBER:
342700683
ADMINISTRATOR:YESENIA JONESFACILITY TYPE:
740
ADDRESS:18 KADO CTTELEPHONE:
(916) 395-7579
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:125CENSUS: 88DATE:
04/16/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brittany Yamada TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
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5
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9
1) Residents did not have access to drinking water
INVESTIGATION FINDINGS:
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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, the allegations cannot be substantiated. LPA has determined the facility water supply is from municipal sources and therefore, per title 22 regulations is not subject bacteriological analysis required of facilities who receive water from a private source. The complaint alleges the resident's in memory care are not given filtered water; there are no such requirements under title 22 regulations.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250609113259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ACC MAPLE TREE VILLAGE
FACILITY NUMBER: 342700683
VISIT DATE: 04/16/2026
NARRATIVE
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4