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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880833
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:44:41 PM

Document Has Been Signed on 12/04/2024 03:44 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/
DIRECTOR:		HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:1065 W HUFF STREETTELEPHONE:
(909) 440-5252
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 8CENSUS: 7DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Ahmad Abdallatef- Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:56 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver, Maribel Barnes and was granted entry to the facility. LPA was accompanied by Maribel to conduct a general overall inspection, which included, but was not limited to, the following:

The facility has 5 bedrooms, 3 bathrooms, kitchen, dining area, living room, office area, laundry room, garage and backyard. LPA completed a walk through of facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 68 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed that the couple bedroom did not have an appropriate sized bed. Deficiency issued. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 123 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, ombudsman, and license were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to residents. LPA observed that the facility did not have sanitary pads. Deficiency issued. Residents/Staff files were observed locked and made inaccessible. There are no bodies of water, firearms or ammunition in the facility. LPA observed two broken window screens, a broken air conditioner and window bars in one of the resident's bedroom upstairs. Deficiency issued.

Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Dishes, cups, and utensils were stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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 6
Document Has Been Signed on 12/04/2024 03:44 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/04/2024 at 02:40 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: 12/04/2024

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 observation and interview, the assistant administrator did not comply with the section cited above by not having the facility safe and in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Assistant administrator stated that he will replace the two bedroom window screens, remove the window rail from the bedroom upstairs and repair the air conditioner unit by POC and send proof of invoices, receipts and items corrected to LPA via email by due date.
Type B
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the assistant administrator did not comply with the section cited above in providing an appropriate sized bed for the couple which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant Administrator stated he will replace the couple's bedroom by providing them with an appropriate sized bed and sent pictures to LPA via email by POC due date.
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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/04/2024 03:44 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/04/2024 at 02:40 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: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(D)
Personal Accommodations and Services
(D) Hygiene items of general use such as soap and toilet paper.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the assistant administrator did not comply with the section cited above by providing sanitary pads which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant administrator stated that he will purchase sanitary pads and submit proof of pictures to LPA via email by POC due date.
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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/04/2024 03:44 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/04/2024 at 02:40 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: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the assistant administrator did not comply with the section cited above by not having a facility fully staffed with staff present at all times which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant Administrator stated that he will update the staff schedule and be fully staffed at all times and submit a statement of understanding to LPA via email by POC due date.

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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/04/2024 03:44 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 12/04/2024 at 02:40 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: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the assistant administrator did not comply with the section cited above by not encouraging residents to participate in activities due to the activities schedule was not being followed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Assistant administrator stated that he will review and update the activity schedule and ensure that staff are following it. Assistant administrator will submit a statement of understanding to LPA via email by POC due date.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the assistant administrator did not comply with the section cited above by not having the residents records updated and complete which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Assistant Administrator stated that he will review, update and correct the residents admission agreements, appraisals, and physician's report and submit proof to LPA via email by POC due date.
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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
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
VISIT DATE: 12/04/2024
NARRATIVE
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Yards/Outside: One shaded patio, two sheds used for storage and a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: LPA observed that the facility did not have sufficient staff present and the schedule was not followed accordingly. Deficiency issued.

Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed issues on the residents records like admission agreements not acknowledged by the residents or responsible party, LIC602 not updated annually according to the resident's diagnosis, and appraisals not reevaluated. Deficiency issued. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medication was audited and matched with record. LPA reviewed the liability insurance, emergency disaster plan and disaster drills. LPA observed that the facility is not performing the activities scheduled. Deficiency issued.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to Assistant Administrator, Ahmad Abdallatef who arrived in the middle of the tour.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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