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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800144
Report Date: 03/24/2022
Date Signed: 03/24/2022 04:21:31 PM

Document Has Been Signed on 03/24/2022 04:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:NICK'S MAPLE HOME LLCFACILITY NUMBER:
361800144
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
735
ADDRESS:9008 S MAPLE AVENUETELEPHONE:
(786) 219-6008
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY: 22CENSUS: 22DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Ahmad AbdallatefTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/24/2022 at 02:30 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Ahmad Abdallatef and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Ahmad Abdallatef and Administrator Ahmad Abdallatef reported that Mitigation Plan was submitted 10/01/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. LPA Brown toured the facility and observed that client bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks, isolation gowns but no face shields/goggles. LPA Brown will be issuing a Technical Assistance Advisory Note instead of a deficiency due it being difficult to access face shields at numerous points during the COVID-19 pandemic. LPA Brown advised the facility to look online for items missing from their PPE supply kit, as CCL and Inland Regional Center may not have these items to supply them with.

LPA Brown went over the various recommended training for facility staff with Administrator Ahmad Abdallatef in relation to COVID-19 and Administrator Ahmad Abdallatef reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.



LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Ahmed Ahmad Abdallatef informed LPA Brown that at this time staff have not been fit tested. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NICK'S MAPLE HOME LLC
FACILITY NUMBER: 361800144
VISIT DATE: 03/24/2022
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LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, all residents and most staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Brown informed Administror Ahmad Abdallatef of the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients for COVID-19, when and how to isolate/quarantine client, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their client regularly for any changes in condition and to subsequently notify the clients physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the visit, LPA Brown requested staff vaccination records and on 03/24/2022 at 02:45 PM, LPA Brown observed that Staff 2 is not vaccinated and no exemption on file. Administrator Ahmad Abdallatef reported that due to medical condition, Staff 2 is not vaccinated but is testing for Covid-19 weekly. LPA Brown informed Administrator Ahmad Abdallatef that Staff 2 needs to have a Medical Exemption on file or get the Covid-19 vaccine. LPA Brown will be issuing Technical Violation.

In addition, LPA Brown observed no carbon monoxide detector at the facility. LPA Brown will be issuing a deficiency as this poses a potential health, safety or personal rights risk to clients in care.

An exit interview was conducted with Administrator Ahmad Abdallatef and a copy of this report (LIC809), LIC 809D, LIC9102 AN Technical Violation, Technical Assistance Advisory Notes, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2022 04:21 PM - It Cannot Be Edited


Created By: Melody Brown On 03/24/2022 at 03:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NICK'S MAPLE HOME LLC
FACILITY NUMBER: 361800144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having carbon monoxide detectors at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
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Licensee stated to purchase and install carbon monoxide detectors today and will submit proof to LPA Brown by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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