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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880833
Report Date: 11/09/2022
Date Signed: 12/30/2022 02:19:10 PM

Document Has Been Signed on 12/30/2022 02:19 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 IIFACILITY NUMBER:
361880833
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:1065 W HUFF STREETTELEPHONE:
(909) 440-5252
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 8CENSUS: DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:13 PM
MET WITH:Maribel Barnes, CaregiverTIME COMPLETED:
04:30 PM
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LPAs Amber Coleman and Anna Bueno arrived at the Nick Maple Home II to conduct an unannounced visit for annual inspection with a focus on infection control. LPA's were greeted and invited inside by Staff Member (S1), Maribel Barnes. LPA's introduced themselves and discussed the purpose of the visit. S1 requested that LPA have temperature taken and sign into the facility's log. LPA observed a COVID station equipped with sufficient PPE, hand sanitizer and disinfectant solutions. S1 contacted the Facility Administrator Ahmed Abdallatef who later arrived to the facility. Administrator reported confirmed that there are currently no cases/exposures of COVID-19 within the facility.

LPA Coleman conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA observed appropriate infection control postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). 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, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division (CCLD) guidelines for COVID-19 testing, isolating/quarantining residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms. LPA also reviewed resident records and interviewed Licensee.

During the visit, technical violations are being issued due to a shed in the backyard area, that is being used for staff quarters. An identified staff room being converted to a client room with 1 bed. Also, observation of expired food products in the kitchen pantry. Licensee will submit a new facility sketch.

Exit interview was conducted and discussed with S1 and a copy of this report LIC 809 was provided during this visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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