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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880833
Report Date: 11/03/2023
Date Signed: 11/15/2023 04:11:34 PM

Document Has Been Signed on 11/15/2023 04:11 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: 6DATE:
11/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marebelle Barnes, CaregiverTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at Nick’s Maple Home II to conduct an unannounced complaint visit for #56-AS-20230426113048 & 56-AS-20231101125452 During visit, LPA observed deficiencies not related to the complaint allegations.

LPA reviewed two, (2) resident files. 2 out of 2 resident files were incomplete. LPA observed that R1’s Physician’s Report was out of date. LPA observed that the date printed on the Physician’s Report was 1/7/2021. R2's resident file was missing the Physician's Report. Administrator agreed to contact R2's Medical Offices to have the Physician's Report completed.

At approximately, 1:35pm LPA walked through the facility's backyard. Upon exiting the facility through the sliding doors, laid a an orange water hose. LPA observed a shovel and a rake leaned up against the side wall of the facility. LPA observed another rake leaned up against the perimeter gate. Along the left side pathway of the facility is a shed. The shed door was observed ajar. Inside the shed were wheelchairs, walkers, unidentifiable medical equipment, and two, (2) bottles of chemicals/toxins. LPA walked to the right exterior pathway where another shed is located. The door to this shed was open. Inside the shed were large numbers of yard tools, power tools, chemicals and sharp objects. Leaned up against the shed were additional yard tools. LPA observed 2 parked vehicles in the backyard. A blue colored sedan along with a white pick up truck. The 2 vehicles obstruct the evacuation route of the facility. Residents in care often utilize walkers and wheelchairs. The two vehicles obstruct the pathway; preventing residents from getting wheelchairs or walkers through the walkway. LPA discussed observations and concerns with Administrator Ahmad Abdallatef, who coordinated with staff to make the corrections during the visit. Administrator rolled up the water hose, secured all of the yard tools moving them to the sheds. The sheds were then secured. The two vehicles were also removed from the backyard to unobstruct the pathway out of the facility.

At approximately 1:50pm LPA requested the staffing schedule and the food menus as they were not posted. Administrator reported that the facility food menu and staffing schedule would need to be created and submitted to LPA at a later time/date.

Based on observations and record reviews, a deficiencies will be cited to address the above-mentioned concerns. Please see attached LIC809-D. An exit interview was conducted, this report was reviewed, discussed, and then provided to the facility Representative.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2023
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 11/03/2023 03:41 PM - It Cannot Be Edited


Created By: Amber Coleman On 10/29/2023 at 04:30 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 II
FACILITY NUMBER: 361880833

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2023
Section Cited
CCR
80069(1)(a)

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80069 Client Medical Assessment The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.
This requirement is not met as evidenced by:
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Administrator agrees to assist the resident 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
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Based on a review of records, Administrator failed to obtain and maintain R1's Physician's report within 1 year which poses a potential Health, Safety, and/or personal rights risk to persons in care.
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to Community Care Licensing within the next 30 business days.
Type B
12/04/2023
Section Cited
CCR80022(a)(5)

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Plan of Operation - (a) Each licensee shall have and maintain on file a current, written, definitive plan of operation. (5) Staffing plan, qualifications and duties, if applicable.
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Administrator agrees to create a staffing schedule for the month or the week - whichever is preferred, post the staffing schedule and submit verification of that schedule to Community Care Licensing within the next 30 business days
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Based on observation and staff interviews, Administrator failed to have the staffing schedule posted or made available to Licensing Staff during the visit.
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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:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/15/2023 04:12 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/08/2023 08:54 AM


Created By: Amber Coleman On 11/03/2023 at 03:00 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
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: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2023
Section Cited
CCR
80022(9)

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80022 Plan of Operation - Sample menus and a schedule for one calendar week indicating the time of day that meals and snacks are to be served.
This requirement was not met as evidenced by:
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Administrator agrees to create a food menu for the month or the week - whichever is preferred, post the staffing schedule and submit verification of that schedule to Community Care Licensing within the next 30 business days.
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Based on observations, Adminsitrator failed to post/maintain a facility food menu. When LPA requested to view the food menu, the menu could not be produced. This poses a potential Health, Safety and Personal Rights Risk to persons in care.
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Type B
12/08/2023
Section Cited
CCR87309(a)

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87309 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.
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Administrator collected all yard tools, placed them inside the sheds and secured the shed during visit. The water hose was rolled up and placed in a corner out of the main walk way. Both the blue sedan and white pick up truck removed from the backyard.
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This requirement was not met as evidenced by:
Based on observations and interviews, Administrator failed to ensure that all chemicals and other dangerous items were not secure. LPA observed two open sheds in the facility's backyard. Sheds contained yard tools and chemicals/toxins accessible to residents in care. This poses a potential Health, Safety and Personal Rights risk to persons in care.
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LPA took photographic evidence for verification. Administrator agreed to submit a statement of understanding of the above mentioned regulation and submit the statement 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 Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
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