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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881035
Report Date: 03/20/2023
Date Signed: 03/20/2023 10:19:19 AM

Document Has Been Signed on 03/20/2023 10:19 AM - 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 IIIFACILITY NUMBER:
361881035
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:2838 N. IRONWOOD AVETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 10CENSUS: DATE:
03/20/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Najeh HamedTIME COMPLETED:
10:20 AM
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On this day, Licensee Najeh Hamed and Licensing Program Analysts (LPA) Anna Bueno met at the San Bernardino Regional Office. The purpose of today's meeting is to deliver findings on complaint number 56-AS-20221104151616.

During the investigation of the above mentioned complaint the following violations were discovered. Refer to LIC809-D for deficiency cited.

Violation discovered are listed below:
      • 87208(c) Resident records revealed one resident has a diagnosis of Dementia. This facility has not submitted to a Dementia care plan to the Department and therefore is not authorized to provide care and supervision to residents with Dementia.
      • 87204(b) The facility license identifies first floor bedroom as the only non-ambulatoy bedroom. During the investigation, Resident 1 was occupying bedroom #5 in the second floor.
      • 87506(b) Nine resident records were reviewed and all had missing documents such as, LIC 602 Physician's report, admission agreement, Pre-admission appraisal and/or re-appraisal.

An exit interview was conducted with and a copy of this report, LIC809-D, and appeal rights
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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 3
Document Has Been Signed on 03/20/2023 10:19 AM - It Cannot Be Edited


Created By: Anna Bueno On 03/13/2023 at 08:53 AM
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 III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2023
Section Cited
CCR
87208(c)

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(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).
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Licensee shall relocate resident with Dementia to an appropriate facility.
Proof of resident relocation shall be submitted to the Department no later than the end of POC date.
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This requirement was not met as evidenced by:

One of 9 resident records revealed that one resident is diagnosed with Dementia. This poses an immediate health and safety risk to residents in care.
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The licensee is encouraged to submit a Dementia care plan for review and approval by the Department if they wish to retain residents with Dementia. Licensee was instructed not to admit such residents until the facility is licensed for this type of care and supervision.

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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:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE:
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/20/2023 10:19 AM - It Cannot Be Edited


Created By: Anna Bueno On 03/13/2023 at 08:59 AM
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 III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2023
Section Cited
CCR
87204(b)

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Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate non ambulatory residents. Residents whose condition becomes non ambulatory shall not remain in rooms restricted to ambulatory residents.
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Licensee shall relocate Resident 1 to an appropriate setting.
Proof of resident relocation shall be submitted to the Department no later than the end of POC date.
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This requirement was not met as evidenced by:

Resident 1 is non-ambulatory is occupying bedroom #5. Fire clearance only allow the 1st floor bedroom to be occupied by non-ambulatory clients. This poses a potential health and safety risk to residents in care.
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Type B
03/29/2023
Section Cited
CCR87506(b)

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Resident Records
(b) Each resident’s record shall contain at least the following information... (1) through (17)(F)

This requirement was not met as evidenced by:

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Licensee shall complete all records listed in section 87506(b), with the correct facility name as appropriate.
Proof of correction shall be submitted to the Department no later than the end of POC date.
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Nine resident records were reviewed and all had missing documents such as, LIC 602 Physician's report, admission agreement, Pre-admission appraisal and/or re-appraisal.
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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:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
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