NICK'S MAPLE HOME II

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Operated Facilities: (a) In addition to the rights listed in Section 87468.1,.. personal rights: (4) To care, supervision, and services that meet their individual needs and are...their needs. This requirement is not met as evidenced by: On December 1, 2025, LPA arrived unannounced to the facility and observed the facility did not have any staff present in the facility, residents were left unsupervised and facility keys were left and unsecured which poses a health and safety risk for residents in care.

Official plan of correction

Administrator stated that he will conduct training with staff on regulation cited and submit proof of scheduled of staff and hours work to LPA via email by POC due date. Administrator will also later submit staff attendance sheet to LPA once completed.

Deadline recorded: Dec 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, and record review, the licensee did not comply with the section cited by not ensuring that all staff records are updated and maintained. LPA observed that 6 out of 7 staff were missing proof of criminal clearance, health screening/TB test, training, or CPR which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/26/2025 Plan of Correction Administrator agrees to update all personnel file and ensure that all staff are CPR certificate, health screening/TB test results, current training, and job description available for review. Administrator agrees to complete a statement of understanding and provide updated documents to LPA by POC due date.

Official classification

Type B

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not monitoring and maintaining the water temperature. LPA observed the water temperature measured at 133.4, 134.3, and 156.6 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/11/2025 Plan of Correction Administrator agrees to complete a daily monitoring of the water temperature and purchase signs that stated caution hot etc. Administrator agrees to review the regulation cited and submit a statement of understanding to LPA by POC due date.

Official classification

Type B

Official code

87467(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, and record review, the licensee did not comply with the section cited above by not ensuring the facility maintained a annual needs and service plan for 1 out of 3 residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/26/2025 Plan of Correction Administrator agrees to review and update all residents file to completed and up to date the needs and service plan. Administrator agrees to maintain all residents file for a annual review of the needs and service form LIC625 and submit a statement of understanding to LPA by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 12/11/2024 Plan of Correction 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.

Official classification

Type B

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction 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.

Official classification

Type B

Official code

87307(a)(3)(D)

Regulation authority

CCR

What the official deficiency says

(D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Assistant administrator stated that he will purchase sanitary pads and submit proof of pictures to LPA via email by POC due date.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction 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.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction 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.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 12/11/2024 Plan of Correction 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.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made in the fcaility's backyard the licensee did not comply with the section cited above in by not ensuring dangerous items were secured and inaccessible to residents; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/11/2023 Plan of Correction Administrator made the corrections during the facility visit by securing dangerous items in the facility's yard shed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements - (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences,... which threaten the welfare, safety or health of residents... shall be reported within 24 hours either by telephone or facsimile to the licensing agency... This requirement is not met as evidenced by: Based on observations and review of records, the Administrator failed to report 2 special/unusual incident reports to the licensing office within the required timeframe.

Official plan of correction

Administrator agrees to work with staff to develop a plan to submit Incident Reports to the Community Care Licensing Office within the regulated timeframe. Administrator aggrees to put the plan in writing and submit the plan to the community Care Licensing Office within the folllowing business day.

Deadline recorded: Nov 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80069(1)(a)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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 to Community Care Licensing within the next 30 business days.

Deadline recorded: Nov 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80022(a)(5)

Regulation authority

CCR

What the official deficiency says

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. Based on observation and staff interviews, Administrator failed to have the staffing schedule posted or made available to Licensing Staff during the visit.

Official plan of correction

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

Deadline recorded: Dec 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80022(9)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Dec 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

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. 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.

Official plan of correction

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. 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.

Deadline recorded: Dec 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80072(a)(3)

Regulation authority

CCR

What the official deficiency says

80072 Personal Rights - ....each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, ...or other actions of a punitive nature, including but not limited tofunctions, including eating... This requirement was not met as evidenced by: Based on observations and interviews the Administrator prevents residents access to the food supply during the evenings by keeping the pantries and refridgerator locked which poses an immediate Health, Safety and Personal Rights risk to persons in care.

Official plan of correction

Administrator unlocked the facility pantries during the visit and agreed to keep them unlocked and informed staff to keep them unlocked. Administrator agrees to submit a statement of undertaning of the violation and to keep the food supplies unlocked.

Deadline recorded: Nov 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80076(4)

Regulation authority

CCR

What the official deficiency says

80076 Food Services (4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician. This requirement is not met as evidenced by: Based on observation the licensee did not provide residents with acecess to their food supply which poses an immediate Health, Safety and Personal Rights risk to persons in care.

Official plan of correction

Licensee agree removed the chain and lock from the refridgerator in LPA presence, therefore completing the plan of correction.

Deadline recorded: May 1, 2023. A deadline is not proof that correction was completed.