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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 10/08/2025
Date Signed: 10/08/2025 04:05:01 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
10/01/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20251001144234
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: DATE:
10/08/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Yesenia JonesTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Food Service: Food items are not being stored as required by regulations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at ACC Maple Tree Village RCFE on 10/8/25 at 9:15am to inform the licensee of complaint allegation mentioned above and to deliver findings.

Based on LPA observations during the investigation process, the allegations are substantiated. LPA conducted a walk through of the kitchen, inspected freezer and refridgerator and dry goods storage. LPA observed expired food items in the fridge. LPA observed expired and undated/unlabeled items in dry storage. LPA also observed boxed food items being stored on the floor of the freezer.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Food Service is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
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-20251001144234
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: 10/08/2025
NARRATIVE
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The following deficiency is cited per California Code of Regulations, TITLE 22. An immediate civil penalty will be issued during today's inspection.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20251001144234
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: 10/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2025
Section Cited
CCR
87555(b)(9)
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Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.This requirement was not met as evidenced by LPA observations of food being stored on the floor, expired items located in the fridge and dry storage, unlabled items being stored in dry storage containers. and several other dry storage items being expired per the lable wich poses an immediate health, safety and personal rights risk to residents in care.
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 Facility has agreed to immediately schedule a consultation from a qualified person and share the documetented results of the consulation.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
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