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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 06/02/2026
Date Signed: 06/03/2026 01:28:49 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: 91DATE:
06/02/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jeannette ElliottTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is not serving meals in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on June 02, 2026, at 9:15 AM to deliver complaint findings, LPA Martinez met with Jeannette Elliott, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, conducted food supply inspections, and observed prepared meals, and observed meals being served. Based on interviews it was learned that the facility table service procedures were causing disorganization in regards to serving meal plates and attending residents in care during mealtimes. It was also learned that there were limited kitchen staff members during mealtimes due to scheduled rest breaks. The facility has implemented new table service procedures and work schedules to improve meal service. 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. Deficiency 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026
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 2
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: 06/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2026
Section Cited
CCR
87555(b)(18)
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General Food Service Requirements 87555(b)(18): Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met as evidence by: based on interviews,
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Facility has hired five servers and created a new time schedule for serving meals. Has implemented ongoing training for servers. Has implemented new table service procedures.
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file reviews, observation, the Licensee did not ensure food service personnel were meeting the needs of the residents and serving meals timely.
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Facility staff agrees to conduct daily serving audit, and email LPA Martinez audit findings weekly until September 1, 2026.
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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: 06/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2