Routine inspection·January 5, 2024

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 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 CPR/First Aid, also out of date.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.