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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 06/04/2026
Date Signed: 06/04/2026 02:52:33 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
05/15/2026 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260515111823
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:
06/04/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ylvyra AbareTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff mismanage resident's medication.
Staff do not ensure medication is kept in its original container.
Staff falsify medication administration records.
Staff yells at resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on June 04, 2026, at 9:15 AM to deliver complaint findings, LPA Martinez met with Ylvyra Abare, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, inspected medication room, and reviewed medication administration records (MAR). Based on interviews Staff 1 (S1) does not administer medication, and S1 reported they do not administer medication. S1 also, reported they did not administer ear drop medication into resident's 1 (R1) eyes. LPA Martinez interviewed resident 1 (R1), and R1 reported that facility staff do not administer ear drops into their ears. R1 also reported that staff do administer any medicine into their eyes. LPA Martinez reviewed R1's MAR, and the MAR does not show that R1' has an open order for ear drops. During medication room inspections, LPA Martinez observed that medication were kept in their original container. LPA Martinez reviewed six medication administration records and did not observe any discrepancies.
Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
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 2
Control Number 27-AS-20260515111823
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: 06/04/2026
NARRATIVE
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Five out of five residents reported that no staff has mistreated them or yelled at them. Five out five staff reported that they have never yelled at a resident.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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