Nick's Maple Home III

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) LaVette Farlow arrived to facility to conduct a complaint investigation regarding the above allegation. LPA Farlow was greeted and granted entrance into the home by Caregiver, Sharef "Sean" Awad. LPA Farlow asked Caregiver Sean to notify the administrator of my arrival. LPA spoke to Administrator, Ahmad Abdallatef and Yusef Nofal via phone and explained the purpose of the visit and the complaint elements. During the course of the investigation the LPA conducted interviews with resident, staff and relevant parties. LPA reviewed records, obtained copies of documentation from residents. The allegation is the facility conducted an illegal eviction. LPA interviewed staff, resident, and relevant parties. LPA interviews revealed that R1 was not given a 30 day notice advising R1 of the move. R1's Conservator or Social Worker were not aware of the move and was not notified of a need to move. LPA interview with staff revealed that the facility moved the wrong resident and there are two (2) residents with similar names. ***continued on LIC 9099C*** Substantiated LPA was informed that R1 was returned to the facility but has since moved to another facility. Due to the eviction procedure not being followed and proper notification was not provided to R1 or his responsible parties, such as his conservator or social worker the allegation is SUBSTANTIATED. The illegal eviction procedure was met by not following the Health and Safety standard per regulation 1569.682 (2)(A), Eviction Procedures. Based on the aforementioned, we have SUBSTANTIATED the complaint allegation as valid. A violation has occurred based on the preponderance of available evidence. A copy of this report LIC9099, LIC9099C, LIC9099D, and appeal rights are being reviewed and provided to the Administrator, Hamza Abuawad.the state’s words, verbatim · CDSS document, May 18, 2026 · control 56-AS-20260304150013

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.682(2)(A) · Plan of correction due date: Jun 1, 2026

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.the state’s words, verbatim · CDSS document, May 18, 2026

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.

Type of visit: Required - 1 Year

On 1/14/2026 Licensing Program Analysts, (LPAs) LaVette Farlow and Michelle Echeverria arrived at the Nick's Maple Home III, unannounced to conduct an Annual Inspection. LPAs was greeted by Caregiver, Michelle Manaoang. LPAs introduced self and stated purpose of the visit and was granted entry. Caregiver Michelle notified Administrator, Ahmad Abdallatef of LPAs arrival. LPAs were provided space to work, and conducted a tour of the facility. Administrator Ahmad, and House Manager Malik Salem arrived later and participate during the inspection. Facility: The facility is two (2) story home. It home is a 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. The facility is approved ten (10) of which eight (8) ambulatory two (2) non-ambulatory. The current census is ten (10). There is a hospice waiver in place approval for 2. The temperature throughout the facility is a comfortable 76 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 7, 2025. The facility water was tested and the temperature ranged from 127.9, and 122.3, a technical violation issued. Resident Rooms - Each resident bedroom can accommodate any ambulatory resident. All resident bedrooms were adequately furnished with bed, storage space, chairs, and lighting. Please see LIC809-C 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. Kitchen - The facility 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 and secured in a cabinet near 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. Personnel Records- LPAs reviewed two (2) 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. LPAs observed that 1 out of 2 staff records were incomplete and missing a Health screening and TB test results. A Deficiency cited. Resident Records- LPAs reviewed seven (7) 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. LPAs observed that the Administrator did not have a physicians' report for one resident who was admitted since November 2025. A deficiency cited. LPAs observed resident Admission report were missing signatures, and some were printed double sided and with white out, and the appraisal and pre-appraisal were missing signatures. A deficiency cite. LPAs observed a first aid kit, and it was complete. Backyard/Outdoor Space: LPAs observed the facility patio, with a shaded area with chairs. The Laundry space was observed en route to the attached garage. It contained operable washer and dryer. ***Continued LIC809C*** LPAs 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 one technical violation and three deficiencies were cited per Title 22, Division 6 of The California Code of Regulations. The report LIC809, LIC809C, LIC809D, and appeal rights were reviewed and a copy provided to Administrator Ahmad Abdallatef.the state’s words, verbatim · CDSS document, Jan 14, 2026

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff are not providing adequate food service Staff do not keep kitchen clean and orderly

Licensing Program Analyst (LPA) LaVette Farlow arrived to facility to conduct a complaint investigation regarding the above allegations. LPA Farlow was greeted and granted entrance into the home by Caregiver, Michelle Mangaong. LPA Farlow asked Caregiver Michelle to notify the administrator of my arrival. LPA met with Administrator, Yousef Nofal and Ahmad Abdallatef explained the elements of the complaint. The allegation is staff are not providing adequate food service. LPA Farlow investigation consist of an tour of the facility, record review, interviews with residents, and staff. LPA interviewed seven (7) residents. Seven (7) out of seven (7) residents stated staff have adequate food service. Residents stated the facility has plenty of food for residents in care. Seven (7) out of seven (7) residents stated staff provide plenty of food and a variety of different meals to eat. LPA interviewed three (3) out of three (3) staff. The results from the interview with the three staff revealed that staff provide adequate food service for resident in care. Staff stated we conduct a weekly grocery store run. LPA observed S2 cooking in the kitchen using gloves and the food was covered. During the visit LPA observed another staff delivering grocery to the facility. ***continued on LIC 9099C*** Unsubstantiated The second allegation is staff do not keep kitchen clean and orderly. LPA interviewed seven (7) out of seven (7) residents and all the residents stated S2 is a hard worker and does a very good job at keeping the kitchen clean and in order. Upon LPA's arrival I observed S2 preparing a meal. LPA observed the food was covered, the kitchen was clean and orderly. LPA did not observed any flies on the food or on the eating utensils. LPA interviewed three (3) out of three staff. Three (3) out of three (3) staff stated the facility keeps the kitchen clean and in order. Based on information above, the allegations is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Yousef Nofal and Ahmad Abdallatef, Adminsitrator and a copy of this report LIC9099, and LIC9099C was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 56-AS-20250801122654

Allegation investigated: Staff coerced resident to enroll in alternative insurance plan.

Licensing Program Analyst (LPA) LaVette Farlow arrived to facility to conduct a complaint investigation regarding the above allegation. LPA Farlow was greeted and granted entrance into the home by Caregiver, Michelle Mangaong. LPA Farlow asked Caregiver Michelle to notify the administrator of my arrival. LPA met with Administrator, Ahmad Abdallatef and explained the elements of the complaint. The allegation is staff coerced resident to enroll in alternative insurance plan. LPA Farlow investigation consist of an tour of the facility, record review, interviews with residents, and staff. LPA interviewed five (5) residents. Four (4) out of five (5) residents stated staff have not forced or coered them to switch insurance plan. Five (5) out of five (5) residents stated staff assist them with medical appointments. LPA reviewed residents file and observed that residents have varies medication insurance programs. LPA interview with R1 revealed that R1 stated the staff coered R1 to change insurance coverage. LPA interviewed three (3) out of three (3) staff. The results from the interview with the three staff revealed that staff did not coerced resident to enroll in alternative insurance plans. ***continued on LIC 9099C*** Unsubstantiated Based on information above, the allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Michelle Mangaoang, Caregiver and a copy of this report LIC9099, and LIC9099C was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 25, 2025 · control 56-AS-20250723152835

Allegation investigated: Staff are not ensuring that residents are administered their medication(s) as prescribed. Staff are not providing medical supervision to resident in care as needed.

Licensing Program Analyst (LPA) LaVette Farlow arrived to facility to conduct a complaint investigation regarding the above allegations. LPA Farlow was greeted and granted entrance into the home by Caregiver, Michelle Mangaong. LPA Farlow asked Caregiver Michelle to notify the administrator of my arrival. LPA met with Administrator, Ahmad Abdallatef and explained the elements of the complaint. Allegation 1: Staff are not ensuring that residents are administered their medication(s) as prescribed. Regarding the allegation that Staff are not ensuring that residents are administered their medication(s) as prescribed. LPA interviewed four (4) out of four (4) residents and the interview reveal that staff are assisting residents with medication, however after LPA reviewed and audited the MARS log it was found that 3 out of 3 resdients MARS were missing medications and initial were not completed on the MARS. Also, interview with Reporting party, resident, and facility staff revealed there has been a period were R1 and R2 has been without meication. A deficiency was cited. LPA interviewed two (2) out of two (2) staff and it was reveal the staff did not update the MARS with the new prescription medication and PRN meds. ***continued on LIC 9099C*** Substantiated Based on the investigation process, and interviews during todays investigation, allegation #1 Staff are not ensuring that residents are administered their medication(s) as prescribed is SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence the standard has been met. Allegation 2: Staff are not providing medical supervision to resident in care as needed. LPA interviewed 4 out of 4 residents in care and it was revealed that residents are transported to appointment via facility staff or Uber driver. Residents stated they are notified about appointments via facility staff, or social worker. LPA interview with staff revealed that residents are transport to appointments by facility staff. There was one occasion where R1 missed an appointment due to mis-communication, and or lack of a valid contact number. A deficiency was cited. Based on the investigation process, and interviews during todays investigation, allegation #2 Staff are not providing medical supervision to resident in care as needed is SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence the standard has been met. During today’s visit, two (2) deficiencies was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC9099, LIC9099C, LIC9099D, and appeal rights was discussed and a copy provided to Administrator Ahmad Abdallatef, at the end of the visit.the state’s words, verbatim · CDSS document, Apr 25, 2025 · control 56-AS-20250423113821

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80070(a)(10) · Plan of correction due date: May 9, 2025

(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.the state’s words, verbatim · CDSS document, Apr 25, 2025

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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 85075(b) · Plan of correction due date: May 2, 2025

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.the state’s words, verbatim · CDSS document, Apr 25, 2025

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.

Allegation investigated: Neglect/Lack of Care and Supervision.

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Ahmad Abdallatef, Administrator and explained the purpose of the visit. The investigation was conducted by Department staff which consisted of staff interviews, resident interviews and document review. Allegation, Facility staff failed to properly supervise resident resulting in resident sustaining burns on chest and hands. Department staff conducted three (3) staff interviews. Three (3) out of the Three (3) staff stated they were aware that Resident one, R1 had a history of burning himself with cigarettes while smoking. R1 would remove filters from the cigarette and hold the lighted cigarette in hand, burning fingertips and lips. Staff revealed that R1 had a prior incident of burning self, using the stove to light a cigarette. ***Continued on LIC9099C*** Substantiated Staff was aware of this incident, and the Licensee did not provide an updated reappraisal or needs and assessment plan to prevent the issue from reoccurring. Department staff also interviewed four (4) residents. Two (2) out of the four (4) residents indicated they would see R1 smoking cigarettes in the backyard and R1 would burn his fingers while smoking. R1’s social worker, Witness 1 (W1), Nurse Practitioner, Witness 2 (W2) and social worker manager, Witness 3 (W3) stated they were not aware or informed of R1’s behaviors of burning themselves. The facility never notified any of the witnesses of any incidents. Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met. An exit interview was conducted where this report was discussed and reviewed. A copy of this report LIC9099, LIC9099C, LIC9099D, along with appeal rights are being provided to the Ahmad Abdallatef, Administration.the state’s words, verbatim · CDSS document, Apr 21, 2025 · control 56-AS-20240118124025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(4) · Plan of correction due date: May 6, 2025

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.the state’s words, verbatim · CDSS document, Apr 21, 2025

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.

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Jan 21, 2025

The state marks this report as 9 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility did not seek medical attention in a timely manner. Resident was left on the ground for a long period of time.

Licensing Program Analyst (LPA) Bernadette Allen conducted an in-office visit to deliver findings on the mentioned allegation. LPA Allen met with Yusef Nofal-Administrator who was informed of the findings and signed the report. The investigation involved interviews with residents and staff, as well as a review of records. Residents interviewed stated they did not know or remember if Resident 1 (R1) fell and remained on the floor for an extended period. However, interviews with staff members and a review of records indicated that R1 did have a fall and was assisted promptly, receiving medical attention on the same day. LPA was unable to interview R1 as their new location could not be identified. Based on the investigation, the allegation is unsubstantiated. This means that although the allegation may have occurred or is valid, there is not enough evidence to prove whether the alleged violations did or did not occur.An exit interview was conducted with Yusef Nofal-Administrator and provided at the conclusion of the visit with appeal rights. Unsubstantiated An exit interview was conducted, during which this report was discussed and provided to xxx at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 56-AS-20240508151002

Allegation investigated: Staff is financially abusing resident in care.

Licensing Program Analyst (LPA) Bernadette Allen conducted an in-office visit to deliver findings on the mentioned allegation. LPA Allen met with Yusef Nofal-Administrator who was informed of the findings and signed the report. The investigation involved interviews with residents and staff, as well as a review of records. The interviews with residents and staff indicated that they have not been financially abused by staff members and that ROG services act as their payee. The facility files reviewed, including Resident 1 (R1), confirmed that ROG services are listed as the residents' payee. LPA attempted to interview R1, but they no longer reside at the facility and could not be contacted. Based on interviews and evidence gathered during the investigation, the above allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Yusef Nofal-Administrator where this report was discussed and provided to at the conclusion of the visit with appeal rights. Unfoundedthe state’s words, verbatim · CDSS document, Oct 22, 2024 · control 56-AS-20240404104547

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced case management visit to deliver findings and obtain signatures for an amended report. LPA met with staff member, Michelle Mangoaoang. LPA introduced self and stated purpose of the visit. LPA obtained signatures and completed report. An exit interview was conducted where this report was discussed and provided to facility representative.the state’s words, verbatim · CDSS document, Feb 3, 2024

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Jan 5, 2024

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.