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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881035
Report Date: 01/05/2024
Date Signed: 01/05/2024 04:09:12 PM


Document Has Been Signed on 01/05/2024 04:09 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 IIIFACILITY NUMBER:
361881035
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:2838 N. IRONWOOD AVETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY:10CENSUS: 7DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Michelle Mangaong, CaregiverTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Nick's Maple Home III, unannounced to conduct an Annual Inspection. LPA was greeted by Caregiver, Michelle Mangaong. LPA introduced self and stated purpose of the visit and was granted entry. LPA contacted Administrator, Najeh Hamed to notify of LPA visit. No answer to call, LPA unable to leave a voicemail. LPA provided space to work, then a tour of the facility.

Facility: The facility is two, (2) levels. It includes 6 bedrooms, a kitchen, two, (2) living room areas, dining room, laundry space, backyard and attached garage. The facility is approved for a capacity of 10. 8 ambulatory and 2 non-ambulatory. There is a hospice waiver in place approval for 2.

Resident Rooms - Each resident bedroom can accommodate any ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, appropriate linens, storage space and lighting. At approximately 1:22pm LPA observed that Room #3 on the second level is missing a screen on the window. Room #1 on the first level is also missing a screen.

Bathrooms: All bathrooms contained working appliances and adequate hand hygiene and paper supplies. a Hand rails and non-slip grip materials were observed near toilets and in showers/tubs.

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 cabinet under the kitchen sink. 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
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NICK'S MAPLE HOME III
FACILITY NUMBER: 361881035
VISIT DATE: 01/05/2024
NARRATIVE
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Personnel Records/Training/and Staffing- At approximately 2:25pm, LPA reviewed an employee 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 verified the employee had a criminal record/fingerprints on file, but no records for annual training. CPR/First Aid, also out of date. Employee reports the training verification was completed. The records are centrally located at another location.

Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA reviewed ten, (10) 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. Nine, (9) out of 10 records were missing/incomplete physician's reports. Five, (5) resident files were missing Need and Services Assessments.

Backyard/Outdoor Space: At approximately 1:20pm, while inspecting the backyard, LPA observed that yard tools were left out and not secure. At approximately, 1:21pm LPA observed that the exit gate was being held closed with electrical cord posing a potential risk to residents in care attempting to flee in case of an emergency. 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. While observing the facility fire/smoke alarms, LPA observed 2 of the alarms chiming indicating a new battery is needed. Fire extinguishers on both levels of the facility were fully charged; last inspection October 2023. 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.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 01/05/2024 04:09 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 III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of the backyard the licensee did not comply with the section cited above by making sure all of the yard tools were secure. Also leaving electrical wires hanging wtih duct tape attached. Which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Administrator agrees to remove the electrical wires or properly secure them out of reach of residents in care. Administrator agrees to submit verification this has been completed within the next two weeks to the Community Care Licensing Office.
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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 01/05/2024 04:09 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 III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations of the facility, Administrator did not comply with the section cited above by not ensuring all fire/smoke/carbon monoxide alarms contained working batteries. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator agrees to replace the batteries for each chiming fire/smoke/carbon monoxide alarms with working batteries to return the alarms to fully functional condition. Administrator agrees to submit verification this has been completed within the next 30 business days to the Community Care Licensing Office.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations of Resident Rooms #1 and #3 the licensee did not comply with the section cited above by ensuring that each resident window has a properly attached screen. Also, by not making sure the window glass was intact. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator agrees to have the resident room window screens replaced and the cracked window on the first level adressed. Administrator agrees to submit verification this has been completed within the next 30 business days to the Community Care Licensing Office.
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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 01/05/2024 04:09 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 III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above by not ensuring staff files contained updated/current CPR/First Aid Training. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator agrees to have staff complete the CPR/FIrst Aid Training and submit verification of that training to the Community Care Licensing Office within the next 30 business days.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited aboveby not ensuring that complete and accurate staff files are accessible and maintained at the facility for review. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator agrees to submit verification of the staff file with all required completed training to the Community Care Licensing Office within the next 30 business days.
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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 01/05/2024 04:09 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 III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations of the resident records the licensee did not comply with the section cited above by not ensuring that all residents in care maintained client medical asessments which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Administrator agrees to assist the residents in care in making and keeping a doctor appointment to have the resident medically evaluated and complete an updated Physician's Report. Administrator also agrees to submit a copy/verification of the Physican's Report to Community Care Licensing within the next 30 business days.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above by not ensuring a “No Smoking-Oxygen in Use” sign is posted in the facility. This poses/posed a potential health, safety or personal rights risk to persons in care, in that there are residents in care who smoke.
POC Due Date: 01/15/2024
Plan of Correction
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Administrator agrees to have a “No Smoking-Oxygen in Use” sign posted in a prominent place in the facility. Also send verification this task has been completed to the Community Care Licensing Office within the next 30 business days.
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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7