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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700683
Report Date: 08/18/2026
Date Signed: 08/18/2026 02:20:55 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
09/22/2025 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250922083919
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:
08/18/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ylvyra AbareTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff leave resident soiled for an extended period of time.
Staff does not ensure to provide resident adequate clothing.
facility is not meeting residents physcian ordered special diet of pureed foods.
Staff leave resident soiled for an extended period of time.
Staff is mismanaging resident's medications.
INVESTIGATION FINDINGS:
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On August 18, 2026, at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the unannounced facility to deliver complaint findings. LPA Martinez met with Ylvyra Abare during today’s visit and explained the purpose of this inspection visit.

Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and resident records.

Based on a record review, there was not sufficient evidence to support that resident 1 (R1) was left soiled for an exteneded period of time. Four out four facility reported that R1 was not left in soiled clothing or breifs. Three out four care staff reported R1 was assisted with dressing and was always fully clothed. Additionally, there were no documented incidents of R1 not having clothes or missing clothing. It was learned that there were no documented incidents regarding R1 not being provided pureed foods.
Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
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-20250922083919
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: 08/18/2026
NARRATIVE
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LPA Martinez reviewed medication administration notes. The notes indicated that facility staff were contacting R1's hospice agency regarding medication refills and filling new medication orders.

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 allegation are unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Arielle Pascua
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2