Routine inspection·January 21, 2025

Licensing Program Analyst, , (LPA) LaVette Farlow arrived at the Nick's Maple Home III, unannounced to conduct an Annual Inspection. LPA was greeted by Caregiver, Malik Salem. LPA introduced self and stated purpose of the visit and was granted entry. Staff Malik contacted Administrator, Najeh Hamed to notify of LPA visit. LPA provided space to work, then a tour of the facility. Administrator Najeh arrived later and participate during the inspection. Facility: The facility is two, (2) levels. It includes 5 bedrooms, 1 of the 5 bedrooms is for staff, a kitchen, two, (2) living room areas, dining room, laundry space, backyard and attached garage. The facility is approved for a capacity of 10. Eight (8) ambulatory and 2 non-ambulatory. There is a hospice waiver in place approval for 2. The current census is 8 resident in care. The temperature throughout the facility is a comfortable 73 degrees. The facility is equipped with operational smoke alarms, and carbon monoxide detectors. LPA observed two fully charged fire extinguishers. Each one was last inspected October 2024. The facility water was tested and the temperature ranged from 110.4, 117.3, and 118.5, all within regulations. LPA observed the facility did not have a Infection Control Plan available to residents, staff and CCL for review, and the licensee had not conduct the annual review of the emergency disaster plan. Deficiencies cited. Resident Rooms - Each resident bedroom can accommodate any ambulatory resident. All resident bedrooms were adequately furnished with bed, storage space and lighting. LPA observed residents room were missing chairs and proper linen. Administrator corrected the linen and chairs issue prior to the end of the inspection. Technical advisory issued. Bathrooms: All bathrooms contained working appliances and adequate hand hygiene and paper supplies. Hand rails and non-slip grip materials were observed near toilets and in showers/tubs. LPA observed cleaning supplies under the bathroom sink unsecured and accessible residents in care. Deficiency cited. 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 closet by the front door. 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- LPA reviewed 4 employees 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 observed that staff records were incomplete and missing current training records, health screening and TB test results, and annual training for all caregivers. Technical advisory issued. The records are centrally stored and secured. Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA reviewed four, (4) 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. Two, (2) out of (2) MARS records were inaccurate missing/incomplete medications or medication that needs to be disposed of due to discontinuation. LPA observed a first aid kit, but it was incomplete. The first aid kit was missing first aid book, tweezers, plastic scissors, and thermometer. Deficiencies cited. Backyard/Outdoor Space: LPA observed the facility patio, with a shaded area with chairs. During the tour of the backyard, LPA observed that the exit gate leading to the backyard was secured with a dead bolt lock making it inaccessible to resident in care. This poses a potential risk to residents in care attempting to flee in case of an emergency. Deficiency cited. 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. LPA observed fire extinguishers on both levels of the facility were fully charged; last inspection October 2024. 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.