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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 02:58:46 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
05/07/2026 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260507101026
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 do not answer residents calls for assistance timely
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, conducted call button inspections, and reviewed call button logs. LPA Martinez reviewed ten resident call pendent logs from the period of May 15, 2026 to May 18, 2026. The call pendent logs showed that there were twenty-five call pendents that were not responded to within five minuets. The longest wait time was fifty-six minuets and seventeen seconds and the shortest wait time was five minuets and thirty seconds. Moreover, on May 04, 2026, LPA Martinez pressed a call pendent in the memory care unit. Facility care staff did not respond to call pendent because the call pendent alert system volume was turned off. During this call pendent inspection, LPA Martinez requested that the memory call pendent system volume be turned on. Facility staff 1 (S1) ensured that memory call pendent system volume was turned on.
Continued...
Substantiated
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 3
Control Number 27-AS-20260507101026
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: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2026
Section Cited
CCR
87464(f)(1)
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Basic Services 87464(f)(1): Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: based on file
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Facility has implemented new pagers, and Med-Techs now supervise call pendent calls. In-training service was conducted on May 04, 2026 and June 04, 2026. Staff agrees to email LPA Martinez call pendent call procedures and in-service training documentation by June 15, 2026 5:00PM.
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reviews, interviews, observation, the licensee did ensure staff were meeting residents in care needs and providing ADL assistance when needed. This posed a potential 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: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20260507101026
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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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 were 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 3