361880833-12-11-2023-56-AS-ACON-CYERG5-20231211120009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880833
Report Date: 12/11/2023
Date Signed: 12/11/2023 12:00:21 PM

Document Has Been Signed on 12/11/2023 12:00 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	NICK'S MAPLE HOME II		FACILITY NUMBER:	361880833
ADMINISTRATOR:	HAMED, NAJEH		FACILITY TYPE:	740
ADDRESS:	1065 W HUFF STREET		TELEPHONE:	(909) 440-5252
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	8	CENSUS: 6	DATE:	12/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Najeh "Nick" Hamed, Administrator		TIME COMPLETED:	11:45 AM

NARRATIVE

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at Nick's Maple Home II, Residential Care Facility for the Elderly, (RCFE) unannounced to conduct an Annual Inspection. LPA was greeted by Najeh Hamed, Administrator. LPA stated the purpose of the visit and was grated entry inside the facility. LPA was also greeted by Staff Member, Maribel Barnes, Caregiver/Staff member also present during visit. Administrator reported there are 6 residents in care; as two residents have recently relocated.

LPA was accompanied by the Administrator on a tour of the facility to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is approved for 8 residents in care; Six (6) ambulatory and two, (2) non-ambulatory residents. Pathways throughout the facility and the exterior were free of clutter and obstructions. The facility was maintained at 70 degrees in Fahrenheit. Administrator tested both fire and carbon monoxide alarms. Both alarms were observed to be in proper function. LPA observed the facility's two fully charged fire extinguishers - last inspected October 2023. Extra linens and clean towels were observed on the second floor hallway cabinets, sufficient for the number of residents in care. Extra hygiene supplies, toilet paper, hand soap and paper towels were observed secured in a cabinet on first floor near the kitchen. LPA observed resident rooms, each room included a bed/mattress with required linens, sufficient storage for both residents assigned, furniture, lighting and seating. Each resident room appeared orderly. LPA observed sufficient lighting throughout the facility. LPA observed sufficient furniture and adequate seating provided in the living and dining rooms. The hot water temperature tested and observed within regulation. LPA observed posters for resident rights, Long Term Care Ombudsman, theft and loss policy, Administrator Certificates, Resident Roster, LET-US-KNOW, staff schedule, food menu, and Infection Control posted in a prominent area of the facility. Cleaning supplies, toxins, sharps, and other dangerous items were observed in secure areas throughout the facility. The resident's medication records and medications are kept secure in a kitchen cabinet. Resident, Facility and Staff files are kept secure within the same secure cabinet. At approximately,

Please see LIC9099-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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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Document Has Been Signed on 12/11/2023 12:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NICK'S MAPLE HOME II	FACILITY NUMBER: 361880833
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made in the fcaility's backyard the licensee did not comply with the section cited above in by not ensuring dangerous items were secured and inaccessible to residents; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	Administrator made the corrections during the facility visit by securing dangerous items in the facility's yard shed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NICK'S MAPLE HOME II	FACILITY NUMBER: 361880833
	VISIT DATE: 12/11/2023

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10:15am, LPA conducted a walk through of the facility's backyard. LPA observed a leaf blower, (yard tool) placed on the brick ridge. LPA then observed a partially filled gas can sitting on the ground near the shed. At LPA's request, Administrator picked up both items and secured them in the shed during the visit.

Food Service: LPA observed a pantry, cabinets and refrigerators well stocked with canned goods, snacks and dry foods in good standing. Fresh fruit was also observed on the dining room table. LPA observed the facility refrigerator stocked with milk, eggs, breakfast foods, water and juices. Sufficient amounts of both perishable and non-perishable food for the number of residents in care. Sufficient dishes, cups, and utensils were also observed and properly stored. Extra and emergency supplies of food, water, batteries, PPE were located secure in the garage.

Records: LPA reviewed four resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 1 staff file for First Aid/CPR certification, criminal record clearance, training, and health screenings. Each file was found to have all required licensing documents and in good standing.

Based on observations, interviews and record reviews, one deficiencies will be cited per Title 22, California Code of Regulations; to address the yard tool and gas can left accessible. An exit interview was conducted where this report was reviewed, discussed then provided to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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