NICK'S MAPLE HOME III

Official classification

Type B

Official code

1569.682(2)(A)

Regulation authority

HSC

What the official deficiency says

1569.682(2)(A) resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. (A) ...reason for the eviction, with specific facts...determination of the date, place, witnesses... concerning the reasons. This requirement was not met based on interviews conducted. The licensee did not comply with the section cited above by not providing R1 or R1's responsible parties with notification of the move or a reason for the move. R1 nor R1's responsible did not receive a 30 day notice which pose a health and safe risk and violates R1's personal rights.

Official plan of correction

Administrator agrees to review and complete a statement of understanding of the regulation cited and submit a copy to LPA acknowledging te regulation violated.

Deadline recorded: Jun 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 in 1 out of 2 staff by not ensuring the staff had a health screening and TB test results maintain in staff file which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/21/2026 Plan of Correction Administrator agreed to review, complete and maintain a health screen and TB test results in all staff personnel file. Administrator will complete a statement of understanding for the regulation cited and provide proof of health screening and TB test results by POC due date to LPA.

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 and record review, the licensee did not comply with the section cited above in by not ensuring all residents file were maintain with a appraisal, pre-admission appraisal report, or ensuring all records are error free and the use of white out does not appear on resident records which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/28/2026 Plan of Correction Administrator agrees to review, complete and maintain all residents file with a appraisal, pre-admission appraisal report without the use of white out on the documents. Administrator will submit a statement of understanding with the proof of correction by POC due date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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 in by not ensuring prior to admission and acceptance they have a completed LIC602 report for residents ready for review and in residents file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2026 Plan of Correction Administrator stated they have the report and will email it to LPA by 1/16/2026. Administrator agrees to review and update all residents file.

Official classification

Type A

Official code

80070(a)(10)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall..and current record is maintained in the facility for each client. (10) Record of current medications, including the name of the prescribing physician, and instructions..medications. Based on record review, interviews conducted with residents, staff and reporting party, the licensee did not ensure the resident MARS, is maintained, and medication is dispensed and prescribed by physician orders, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to update all residents in care MARS sheet, and conduct a training on maintaining medication and dispensing of medication with a signed log sheet for all staff in attendance acknowledging the regualtion and completion of training by POC date to LPA Farlow.

Deadline recorded: May 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

85075(b)

Regulation authority

CCR

What the official deficiency says

85075(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. Based on interviews, the licensee did not ensure the resident appointment was maintained by not having a valid contact number on file for residents medical provide, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to make sure all medical needs are met and appointments are maintained. Licensee will ensure that all appointment center have a valid contact number to reach him or other staff to ensure appointment are met. Licensee agrees to review all regulation related to licensee responsibility as it relate to providing medical and dental assistance to residents in care and provide a written statement acknowledging the understanding the responsibility to residents in care medical needs, by POC date.

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

Official classification

Type A

Official code

87468.2(4)

Regulation authority

CCR

What the official deficiency says

87468.2(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on interview and record review, the licensee did not comply with the section cited above evidenced by Licensee did not seek proper assistance from the support team to prevent R1 from burning self. Licensee did not follow smoking cessation plan, which imposes an immediate health and safety risk to residents in care.

Official plan of correction

Licensee stated to submit photo documentation of all staff reading over section 87468.2 (4) and submitting to LPA Farlow by Plan of Correction (POC) due date.

Deadline recorded: May 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 locking the perimeter gate to the front and backyard, which does not allow the residents in care to exit freely in case of an emergency. Additionally, not having a Fire Marshall clearance to do so. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/21/2025 Plan of Correction Licensee Najeh Hamed unlocked the perimeter gate during LPA visit. Licensee agrees to complete a statement of understanding of the above regulation by way of a LIC 9098. Licensee agrees to submit this form to the Community Care Licensing Office within 1 business day.

Official classification

Type B

Official code

87470(d)(4)

Regulation authority

CCR

What the official deficiency says

(d) When an emergency, as defined in Government Code section 8558, or federal emergency for a contagious disease is proclaimed or declared, the licensee shall develop an Emergency Infection Control Plan that includes infection control measures that are not already addressed in the Infection Control Plan as specified in subsection (c), to prevent, contain, and mitigate the associated contagious disease. (4) The Emergency Infection Control Plan shall be made available to residents, facility staff and, if applicable, each residents' representative. 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 having an Infection Control Plan ready available to staff, resident in care, or CCL to review. Which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Licensee Najeh will provide documentation/file for the Infection Control plan for the facility and provide training to the staff. License will provide proof of the training and staff that have completed the training, submitting LIC 9098.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 ensuring that cleaning supplies are secured and inaccessible to resident in care. These cleaning supplies not being secured poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Licensee agrees to train staff on the important of securing the cleaning supplies and provide proof of training and a LIC9098.

Official classification

Type B

Official code

87465(a)(8)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: 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 having a complete first aid kit, or book, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/28/2025 Plan of Correction Licensee will provide proof of purchase and pictures after receipt of the completed first aid kit.

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. 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 monitoring the MARS and ensuring medication is properly logged and disgarding when no longer needed. This type of error or inconsistency poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Licensee agrees to conduct training on logging, and maintaining resident in care MARS. Licensee will provide proof of trainging and a log of staff who completed the training.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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 conducting an annual review of the emergency disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/28/2025 Plan of Correction Licensee agrees to review and update the Emeregency disaster plans, post and update records for review, and train staff on the emergency plans.

Official classification

Type A

Official code

87309(a)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation of the backyard the licensee did not comply with the section cited above by making sure all of the yard tools were secure. Also leaving electrical wires hanging wtih duct tape attached. Which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2024 Plan of Correction Administrator agrees to remove the electrical wires or properly secure them out of reach of residents in care. Administrator agrees to submit verification this has been completed within the next two weeks to the Community Care Licensing Office.

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 observations of the facility, Administrator did not comply with the section cited above by not ensuring all fire/smoke/carbon monoxide alarms contained working batteries. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/05/2024 Plan of Correction Administrator agrees to replace the batteries for each chiming fire/smoke/carbon monoxide alarms with working batteries to return the alarms to fully functional condition. Administrator agrees to submit verification this has been completed within the next 30 business days to the Community Care Licensing Office.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations of Resident Rooms #1 and #3 the licensee did not comply with the section cited above by ensuring that each resident window has a properly attached screen. Also, by not making sure the window glass was intact. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/05/2024 Plan of Correction Administrator agrees to have the resident room window screens replaced and the cracked window on the first level adressed. Administrator agrees to submit verification this has been completed within the next 30 business days to the Community Care Licensing Office.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review the licensee did not comply with the section cited above by not ensuring staff files contained updated/current CPR/First Aid Training. Which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/05/2024 Plan of Correction Administrator agrees to have staff complete the CPR/FIrst Aid Training and submit verification of that training to the Community Care Licensing Office within the next 30 business days.

Official classification

Type B

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 observations the licensee did not comply with the section cited aboveby not ensuring that complete and accurate staff files are accessible and maintained at the facility for review. Which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/05/2024 Plan of Correction Administrator agrees to submit verification of the staff file with all required completed training to the Community Care Licensing Office within the next 30 business days.

Official classification

Type B

Official code

87456(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations of the resident records the licensee did not comply with the section cited above by not ensuring that all residents in care maintained client medical asessments which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/05/2024 Plan of Correction Administrator agrees to assist the residents in care 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.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations the licensee did not comply with the section cited above by not ensuring a “No Smoking-Oxygen in Use” sign is posted in the facility. This poses/posed a potential health, safety or personal rights risk to persons in care, in that there are residents in care who smoke.

Official plan of correction

POC Due Date: 01/15/2024 Plan of Correction Administrator agrees to have a “No Smoking-Oxygen in Use” sign posted in a prominent place in the facility. Also send verification this task has been completed to the Community Care Licensing Office within the next 30 business days.

Official classification

Type A

Official code

80019(e)(1)

Regulation authority

CCR

What the official deficiency says

800918 Criminal Record Clearence (e) All individuals subject to a criminal record review... " (1) Obtain a California clearance or a criminal record exemption as required by the Department or The requirement is not met as evidenced by: Based on observation, record reviews and interviews the licensee did not ensure all staff had a criminal records clearence to be employed at the facility which poses an immediate Health and Safety to risk to persons in care.

Official plan of correction

Licensee/Administrator will have Amir Mangaoang leave the facility premises immediately until a criminal record clearence can be obatined.

Deadline recorded: May 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

HSC

What the official deficiency says

87303 Maintenance and Operation (a) 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 was not met as evidenced by: Based on observation, record reviews and interviews the licensee did not ensure facility was in good repair which poses an a potential Health and Safety to risk to persons in care.

Official plan of correction

Licensee/Administrator will have the screen replaced on the window of the resident's room. As well as have the broken window fixed within 30 days.

Deadline recorded: May 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87208(c)

Regulation authority

CCR

What the official deficiency says

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement was not met as evidenced by: One of 9 resident records revealed that one resident is diagnosed with Dementia. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall relocate resident with Dementia to an appropriate facility. Proof of resident relocation shall be submitted to the Department no later than the end of POC date. The licensee is encouraged to submit a Dementia care plan for review and approval by the Department if they wish to retain residents with Dementia. Licensee was instructed not to admit such residents until the facility is licensed for this type of care and supervision.

Deadline recorded: Mar 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87204(b)

Regulation authority

CCR

What the official deficiency says

Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate non ambulatory residents. Residents whose condition becomes non ambulatory shall not remain in rooms restricted to ambulatory residents. This requirement was not met as evidenced by: Resident 1 is non-ambulatory is occupying bedroom #5. Fire clearance only allow the 1st floor bedroom to be occupied by non-ambulatory clients. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee shall relocate Resident 1 to an appropriate setting. Proof of resident relocation shall be submitted to the Department no later than the end of POC date.

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

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

Resident Records (b) Each resident’s record shall contain at least the following information... (1) through (17)(F) This requirement was not met as evidenced by: Nine resident records were reviewed and all had missing documents such as, LIC 602 Physician's report, admission agreement, Pre-admission appraisal and/or re-appraisal.

Official plan of correction

Licensee shall complete all records listed in section 87506(b), with the correct facility name as appropriate. Proof of correction shall be submitted to the Department no later than the end of POC date.

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

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement was not met as evidenced by: Three of 8 records were reviewed and found to be non-ambulatory. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall relocate the non-ambulatory resident that the facility is not licensed to provide care and supervision. Proof of resident relocation shall be submitted to the Department no later than and of POC date.

Deadline recorded: Mar 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80019(e)(1)

Regulation authority

CCR

What the official deficiency says

The nature of the crime including, but not limited to, whether it involved violence or a threat of violence to others. This requirement was not met as evidenced by LPA's observed S1 in the garage of the facility. LPA verified that S1 does not have a criminal record exemption. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall removed S1 from the facility immediately.

Deadline recorded: Nov 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)

Regulation authority

HSC

What the official deficiency says

Deficiency narrative not available.

Official plan of correction

The administrator will ensure that all medications are stored and secured properly at all times by providing additional training to the staff.

Deadline recorded: Jul 22, 2022. A deadline is not proof that correction was completed.