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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881035
Report Date: 01/21/2025
Date Signed: 01/21/2025 03:40:14 PM

Document Has Been Signed on 01/21/2025 03:40 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NICK'S MAPLE HOME IIIFACILITY NUMBER:
361881035
ADMINISTRATOR/
DIRECTOR:		HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:2838 N. IRONWOOD AVETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 10CENSUS: 8DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Najeh Hamed, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst, , (LPA) LaVette Farlow arrived at the Nick's Maple Home III, unannounced to conduct an Annual Inspection. LPA was greeted by Caregiver, Malik Salem. LPA introduced self and stated purpose of the visit and was granted entry. Staff Malik contacted Administrator, Najeh Hamed to notify of LPA visit. LPA provided space to work, then a tour of the facility. Administrator Najeh arrived later and participate during the inspection.

Facility: The facility is two, (2) levels. It includes 5 bedrooms, 1 of the 5 bedrooms is for staff, a kitchen, two, (2) living room areas, dining room, laundry space, backyard and attached garage. The facility is approved for a capacity of 10. Eight (8) ambulatory and 2 non-ambulatory. There is a hospice waiver in place approval for 2. The current census is 8 resident in care. The temperature throughout the facility is a comfortable 73 degrees. The facility is equipped with operational smoke alarms, and carbon monoxide detectors. LPA observed two fully charged fire extinguishers. Each one was last inspected October 2024. The facility water was tested and the temperature ranged from 110.4, 117.3, and 118.5, all within regulations. LPA observed the facility did not have a Infection Control Plan available to residents, staff and CCL for review, and the licensee had not conduct the annual review of the emergency disaster plan. Deficiencies cited.

Resident Rooms - Each resident bedroom can accommodate any ambulatory resident. All resident bedrooms were adequately furnished with bed, storage space and lighting. LPA observed residents room were missing chairs and proper linen. Administrator corrected the linen and chairs issue prior to the end of the inspection. Technical advisory issued.

Bathrooms: All bathrooms contained working appliances and adequate hand hygiene and paper supplies. Hand rails and non-slip grip materials were observed near toilets and in showers/tubs. LPA observed cleaning supplies under the bathroom sink unsecured and accessible residents in care. Deficiency cited.

Kitchen - contained an adequate supply of dry goods, canned goods and non-perishable items for the amount of residents in care. Sharp objects, chemicals/cleaning supplies are maintained securely in a closet by the front door. Additional food items such as milk, bread, eggs, fresh fruits, condiments, cheese, cookies, ice cream, cereals and meats were located in the kitchen refrigerator and two deep freezers in the attached garage.

Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NICK'S MAPLE HOME III
FACILITY NUMBER: 361881035
VISIT DATE: 01/21/2025
NARRATIVE
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Personnel Records/Training/and Staffing- LPA reviewed 4 employees record for first aid certification, finger print clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights and training verification, and current administrator certification. LPA observed that staff records were incomplete and missing current training records, health screening and TB test results, and annual training for all caregivers. Technical advisory issued. The records are centrally stored and secured.

Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA reviewed four, (4) resident files for: admission agreements, medical assessments and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Two, (2) out of (2) MARS records were inaccurate missing/incomplete medications or medication that needs to be disposed of due to discontinuation. LPA observed a first aid kit, but it was incomplete. The first aid kit was missing first aid book, tweezers, plastic scissors, and thermometer. Deficiencies cited.

Backyard/Outdoor Space: LPA observed the facility patio, with a shaded area with chairs. During the tour of the backyard, LPA observed that the exit gate leading to the backyard was secured with a dead bolt lock making it inaccessible to resident in care. This poses a potential risk to residents in care attempting to flee in case of an emergency. Deficiency cited. The Laundry space was observed en route to the attached garage. It contained operable washer and dryer. Door to the attached garage was secure. Inside the garage contained 2 deep freezer for bulk food items.

General/Misc. LPA observed fire extinguishers on both levels of the facility were fully charged; last inspection October 2024. LPA observed the following posters posted throughout the facility: Resident Roster, Resident Rights, Facility License, Emergency/Disaster Plan, Emergency Contact information, Long Term Care Ombudsman, Infection Control and If you see something-say something.

Based on the information observations and review of records during this visit today, the following deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Refer to LIC809D for cited deficiencies. This report and LIC 809D were reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 01/21/2025 03:40 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/21/2025 at 02:54 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
RIVERSIDE, CA 92507

FACILITY NAME: NICK'S MAPLE HOME III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by locking the perimeter gate to the front and backyard, which does not allow the residents in care to exit freely in case of an emergency. Additionally, not having a Fire Marshall clearance to do so. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2025
Plan of Correction
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Licensee Najeh Hamed unlocked the perimeter gate during LPA visit. Licensee agrees to complete a statement of understanding of the above regulation by way of a LIC 9098. Licensee agrees to submit this form to the Community Care Licensing Office within 1 business day.
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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 01/21/2025 03:40 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/21/2025 at 02:54 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
RIVERSIDE, CA 92507

FACILITY NAME: NICK'S MAPLE HOME III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(d)(4)
Infection Control Requirements
(d) When an emergency, as defined in Government Code section 8558, or federal emergency for a contagious disease is proclaimed or declared, the licensee shall develop an Emergency Infection Control Plan that includes infection control measures that are not already addressed in the Infection Control Plan as specified in subsection (c), to prevent, contain, and mitigate the associated contagious disease. (4) The Emergency Infection Control Plan shall be made available to residents, facility staff and, if applicable, each residents' representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above by not having an Infection Control Plan ready available to staff, resident in care, or CCL to review. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee Najeh will provide documentation/file for the Infection Control plan for the facility and provide training to the staff. License will provide proof of the training and staff that have completed the training, submitting LIC 9098.
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring that cleaning supplies are secured and inaccessible to resident in care. These cleaning supplies not being secured poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee agrees to train staff on the important of securing the cleaning supplies and provide proof of training and a LIC9098.
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
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 01/21/2025 03:40 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/21/2025 at 02:54 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
RIVERSIDE, CA 92507

FACILITY NAME: NICK'S MAPLE HOME III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a complete first aid kit, or book, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Licensee will provide proof of purchase and pictures after receipt of the completed first aid kit.
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not monitoring the MARS and ensuring medication is properly logged and disgarding when no longer needed. This type of error or inconsistency poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee agrees to conduct training on logging, and maintaining resident in care MARS. Licensee will provide proof of trainging and a log of staff who completed the training.
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
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/21/2025 03:40 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/21/2025 at 02:54 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
RIVERSIDE, CA 92507

FACILITY NAME: NICK'S MAPLE HOME III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not conducting an annual review of the emergency disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Licensee agrees to review and update the Emeregency disaster plans, post and update records for review, and train staff on the emergency plans.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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