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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 05/04/2026
Date Signed: 05/05/2026 12:50:56 PM

Substantiated


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
05/04/2026 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260504120120
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: 93DATE:
05/04/2026
UNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Ylvyra AbareTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility is not conducting fire drills.
INVESTIGATION FINDINGS:
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On May 04, 2026, at 8:30 AM, Licensing Program Analyst (LPA) Avelina Martinez and Licensing Program Mangager (LPM) Liza King conducted an unannounced facility visit to initiate a complaint investigation and deliver findings for the above allegation LPA Martinez met with Ylvyra Abare and explained the purpose of today’s visit.

During today's facility visit, LPA Martinez and LPM King conducted interviews and obtained facility records. It was learned that fire drills were not being conducted as required. The fire drills are being conducted during all staff meetings, and are not being conducted at each shift. In addition, based on interviews it was learned that residents in care are not invited to partcipate in emergency drills.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
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-20260504120120
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2026
Section Cited
HSC
1569.695(c)
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1569.695(c) Emergency Plans:A facility shall conduct a drill at least quarterly for each shift...An actual evacuation of residents is not required during a drill...While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. This requirement
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 Facility staff agrees to conduct an emergency drill at each shift by 05/05/2026. Facility staff agrees to email LPA Martinez emergency drill documentation by 05/06/2026 by 5:00 PM.
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was not met as evidence by: based on interviews and file reviews. The facility did not conduct emergency drills at each shift and did not provide an opportunity for residents to participate in emergency drills, which poses an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20260504120120
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: 05/04/2026
NARRATIVE
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Resident should be provided the opportunity to participate in emergency drills. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Emergency Plans deficiency is cited on the LIC 9099-D page, per Title 22 Regulations.

An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4