Nick's Maple Home II

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) LaVette Farlow arrived at the facility unannounced to Nick's Maple Home II, to collect signatures for an amended complaint number 56-AS-20231108143629. LPA arrived to the facility and was granted entry by resident one (R1). LPA set up a workstation at the desk in the kitchen. LPA observed (R1) going outside to make a phone call. LPA inquired which staff was present in the facility and LPA was informed that staff left and would return shortly. LPA observed the facility did not have any staff present. R1 handed LPA Farlow the phone and LPA spoke with staff and was informed that someone would be here momentarily. During today's visit, LPA conducted observations, and interviewed to find that residents in care did not have proper supervision and R1 was left with the facility keys, which poses an immediate health and safety risk. Based on LPA's observation this pose an immediate and potential health and safety risk to clients in care. A deficiency was cited. An exit interview was conducted where this report, LIC809, and LIC809D and appeal rights were discussed with and provided to Administrator Yusef Nofal.the state’s words, verbatim · CDSS document, Dec 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 2, 2025

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.the state’s words, verbatim · CDSS document, Dec 1, 2025

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.

Allegation investigated: Staff did not seek medical attention for resident in care in a timely manner. Staff did not prevent resident from wandering from the facility while in care. Staff do not ensure that resident is provided a sufficient amount of food while in care. Staff do not ensure that resident is administered their medication(s) as prescribed. Licensee is financially abusing resident in care. Facility has a pest infestation. Staff do not allow resident(s) to make and receive telephone calls while in care. Staff do not allow resident to have access to their personal possessions while in care.

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to the facility to conclude the investigation and deliver findings to the above mentioned complaint. LPA met with Administrator, Ahmad Abdallatef who was informed of the reason for today's visit. The investigation consisted of interviews with residents and staff, reviewed and collected documents. Allegation 1: It is alleged that staff did not seek medical attention for resident in care in a timely manner. Interview with residents R3, R4, and R8 stated that staff are providing medical attention in a timely manner. LPA interview with S1, S2, S3, and S4 revealed that the facility provides medical attention in a timely manner. Unsubstantiated Allegation 2: It is alleged that staff did not prevent resident from wandering from the facility while in care. LPA interviews with staff and residents revealed that staff is providing proper supervision for residents in care. S4 stated he does not recall a situation where any residents or R1 has wandered off and the police were called. Allegation 4: It is alleged that staff do not ensure that residents are provided a sufficient amount of food while in care. Interviews with R3, R4, R5, and R8 revealed that staff do provide a sufficient amount of food for residents in care. LPA interviewed staff. Interview with, S1, S2, S3 and S4 revealed that staff are providing sufficient amount of food for residents in care. LPA Coleman previous report revealed that LPA observed the facility with sufficient amount of food and the residents had access to food in the facility. During LPA visit today LPA observed the facility has sufficient amount of food for residents in care and the residents had access to food. LPA observed the cabinet, and refrigerator was accessible to residents in care and not locked. Allegation 5: It is alleged that staff do not ensure that residents are administered their medication(s) as prescribed. Interview with residents R3, R4, R5, and R8, revealed that staff are providing medication as prescribed by their doctors. LPA interviewed staff. Interviews with S1, S2, S3 and S4 revealed that staff are dispensing medication according to doctors’ orders. During todays visit LPA audited the residents MARS and there were no discrepancies and medication appears to be dispensed as prescribed. Allegation 6: It is alleged that Licensee is financially abusing resident in care. LPA interviewed residents R3, R4, R5, and R8, and residents stated that they handle their own finances. LPA Coleman reviewed residents files in 2023 and it was revealed that residents are handling their own finances. LPA Farlow interviewed and reviewed residents files and it was revealed that the facility does not manage residents finances. Allegation 7: It is alleged that Facility has a pest infestation. In 2023 LPA Coleman investigation revealed that the Licensee has a monthly Pest Control Service contract with Freedom Pest Extermination Inc. During today’s visit LPA observed the facility still maintains a monthly contract with Freedom Pest Extermination, and LPA Farlow did not observe any signs of an infestation. LPA Coleman interviews with R3, R4, R5, and R8 revealed that the residents were not aware of any problems with pest. LPA Farlow interview with staff revealed that there is not a problem with pest control. Allegation 8: It is alleged that staff do not allow resident(s) to make and receive telephone calls while in care. In 2023 LPA Coleman reviewed documents that revealed the facility maintain a monthly bundle service for cable, internet, and phone service. Also, during the visit in 2023 the Administrator called the facility phone, and LPA Coleman observed the facility maintain an active service. Interview with residents R3, R4, R5, and R8, stated that the residents are allowed access to the facility phone to receive and make calls. Interviews with S1 S2, S3, and S4 revealed that residents are allowed to make and receive phone calls. It is alleged that staff do not allow residents to have access to their personal possessions while in care. LPA Farlow conducted interviews with staff and residents. Interviews with staff S3, S4, and S5 revealed that residents maintain their own personal belongings. Interview with residents R3, R4, and R10 stated that they maintain their own personal belongings. Residents stated they have not been denied access to their personal belongings. LPA Farlow conducted a tour of the facility and observed residents with their personal belongings in their rooms. LPA observed clothing, hygiene items, pictures, books, and varies gadgets. Based on the information above, the allegations are 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 where this report LIC 9099 and LIC9099C was discussed, and a copy was provided to Administrator, Ahmad Abdallatef.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 56-AS-20231108143629

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver, Malik Salem and Administrator, Ahmad Abdallatef and was granted entry to the facility. LPA was accompanied by Ahmad to conduct a general overall inspection, which included, but was not limited to, the following: The facility has 5 bedrooms, 3 bathrooms, 1 of the 5 bedrooms is designated for staff, kitchen, dining area, living room, office area, laundry room, garage and backyard. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 134.3, 133.4, and 156.6 degrees Fahrenheit. Administrator immediately lower the level on the water heater. A deficiency cited. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, ombudsman, and license were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to residents. LPA observed that the facility did have sanitary pads, and personal hygiene items for residents in care. Residents/Staff files were observed locked and made inaccessible. There are no bodies of water, firearms or ammunition in the facility. Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. LPA observed emergency water and food supply in facility hallway closet. Dishes, cups, and utensils were stored properly. Yards/Outside: One shaded patio, two sheds used for storage and a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Care & Supervision: LPA observed that the facility has sufficient staff present and the schedule was posted. Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed one (1) out of three (3) residents were missing a needs and service plan. A deficiency cited. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA reviewed seven (7) staff files. LPA observed six (6) out of seven (7) staff file were missing one of the following documents. health screening/TB test results, training, CPR, or proof of criminal background clearance in their file. A deficiency cited. Medication was audited and matched with record. LPA reviewed the liability insurance, emergency disaster plan and disaster drills. Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to Administrator, Ahmad Abdallatef.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Staff speak inappropriately to residents. Staff preparing meals resident unable to consume.

Licensed Program Analyst (LPA) Lavette Farlow, conducted an unannounced visit to the facility to commence a complaint investigation. LPA was greeted and granted entrance by Caregiver Malik Salem. LPA identified self and discussed the purpose of the visit. LPA also presented self to Licensee, Yusef Nofal and discussed the purpose of the visit. LPA conducted interviews with staff and residents, reviewed documents and did a walk-through of the facility. It is alleged that staff speak inappropriately to residents. LPA interviewed (3) three staff members and four (4) residents. LPA interview with staff revealed that three (3) out of three (3) staff stated they have not spoken to residents in care inappropriately. 3 out of staff stated they have not used profanity with resident in care and staff assist residents as needed with daily ADL's. LPA interviewed four residents in care and it was revealed that four out of four resident stated staff have not spoken inappropriately to residents in care, and five (5) out of (6) residents are able to complete daily ADL's without assistance. It was reveal that a long time ago staff spoken inappropriately to residents in care. Based on interviews, with residents and staff the allegation is UNSUBSTANTIATED. Unsubstantiated It is alleged that staff prepare meals resident are unable to consume. LPA interviewed (3) three staff members and four (4) residents. LPA interview with staff revealed that three (3) out of three (3) staff stated that the residents enjoy the meals and they have not heard any complaints. 3 out of 3 staff stated they ask resident what they would like to eat and encourage residents input on the menu. LPA interviewed four residents in care and it was revealed that four out of four resident were satisfied with the food options and staff provide different meal options. Based on interviews with residents and staff the allegation is UNSUBSTANTIATED. Based on the information above, the allegations are 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 violation did or did not occur. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed, and a copy was provided to Caregiver Malik Salem.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 56-AS-20250915090751

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) LaVette Farlow arrived at the facility unannounced to conduct a Case Management Visit for health and safety. This case management visit is in response to a complaint number 56-AS-20250826085701, submitted to the Community Care Licensing Office. LPA was greeted by Caregiver, Socorro Leon at the front door. LPA introduced self and stated purpose of the visit. During today's visit, LPA conducted interviews, and toured the home. LPA did a health and safety check and reviewed files/records. No deficiencies were observed during this visit. An exit interview was conducted where this report was, reviewed, discussed and then provided to Administrator, Ahmad Abdallatef.the state’s words, verbatim · CDSS document, Sep 3, 2025

Allegation investigated: Staff providing marijuana to resident(s) resulting in resident to relapse.

Licensed Program Analysts (LPA) Lavette Farlow, conducted an unannounced visit to the facility to commence a complaint investigation and deliver the findings. LPA was greeted and granted entrance at the door by Staff, Marebell Barnes. LPA identified self and discussed the purpose of the visit. LPA also presented self to Administrator, Nejah Hamed and Licensee, Yusef Nofal and discussed the purpose of the visit. LPA conducted interviews with staff and residents, reviewed documents and did a walk-through of the facility. It is alleged that staff is providing marijuana to resident(s) resulting in resident to relapse. LPA interviewed (5) five staff members and seven (7) residents. LPA interviewed revealed that five (5) out of seven (7) residents stated they have never witness staff one (S1) sell marijuana to residents in care. LPA interviews with staff one (S1) and staff two (S2) revealed that staff transport residents to the smoke shop, store, appointment and the dispenary, but does not sell marijuana to residents in care. Unsubstantiated Based on the 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 where this report LIC 9099 was discussed, and a copy was provided to Administrator Najeh Hamed.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 56-AS-20250220093618

Type of visit: POC

Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced POC visit in order to inspect for corrected deficiencies cited on 12/04/24. LPA introduced self and was granted entrance by resident 1 (R1). LPA called the Administrator Najeh Hamed and informed him of the purpose of the visit. During today's visit, LPA made interviews, physical observations of the facility and reviewed records. Deficiency 87411(a) has not been cleared. LPA observed upon arriving that the facility was not fully staffed with staff present at all times which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty issued. An exit interview was conducted and discussed, and copies of this report, LIC809, LIC 421FC, and Appeal Rights were provided to Assistant Administrator, Ahmad Abdallatef.the state’s words, verbatim · CDSS document, Dec 12, 2024

Allegation investigated: Resident is being held at the facility against their will. Staff is not allowing resident access to resident's funds.

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to the facility to conclude the investigation of and deliver findings to the above-mentioned complaint. LPA met with Administrator, Ahmad Abdallatef, who was informed of the reason for today's visit. The investigation consisted of interviews with clients, witnesses and staff. It is alleged that resident is being held at the facility against their will. Interview with resident 1 (R1) stated that staff does not allow R1 to attend church or go to the bank. LPAs interviewed five (5) out of five (5) residents in care and three (3) out of four (4) residents stated they are able to leave whenever they want. One resident (R4) refused to answer. Interview with staff revealed that residents are allowed leave the facility, they take the resident on outing and they are not being held against their will. Interview with witnesses (W1) and (W2) revealed that R1 receives visits and goes on outing with family. It is alleged that staff is not allowing resident access to resident’s funds. Interview with R1 stated that staff did not take them to the bank to get their funds. Interview with staff 1 (S1) revealed that the facility does not handle any resident in care funds. All monies are either issued on a debit card or the resident responsible party handles their funds. Interviews with five (5) out of five (5) residents revealed the three residents stated they have full access to the funds. One (1) resident refused to respond. Interviews with W1 and W2 revealed that the family handles funds for R1. Unsubstantiated Based on interviews the above allegations is Unsubstantiated. A finding that complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and this report was discussed and provided to Ahmad Abdallatef, Administrator.the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 56-AS-20240918095317

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver, Maribel Barnes and was granted entry to the facility. LPA was accompanied by Maribel to conduct a general overall inspection, which included, but was not limited to, the following: The facility has 5 bedrooms, 3 bathrooms, kitchen, dining area, living room, office area, laundry room, garage and backyard. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 68 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA observed that the couple bedroom did not have an appropriate sized bed. Deficiency issued. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 123 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, ombudsman, and license were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to residents. LPA observed that the facility did not have sanitary pads. Deficiency issued. Residents/Staff files were observed locked and made inaccessible. There are no bodies of water, firearms or ammunition in the facility. LPA observed two broken window screens, a broken air conditioner and window bars in one of the resident's bedroom upstairs. Deficiency issued. Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Dishes, cups, and utensils were stored properly. Yards/Outside: One shaded patio, two sheds used for storage and a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Care & Supervision: LPA observed that the facility did not have sufficient staff present and the schedule was not followed accordingly. Deficiency issued. Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed issues on the residents records like admission agreements not acknowledged by the residents or responsible party, LIC602 not updated annually according to the resident's diagnosis, and appraisals not reevaluated. Deficiency issued. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medication was audited and matched with record. LPA reviewed the liability insurance, emergency disaster plan and disaster drills. LPA observed that the facility is not performing the activities scheduled. Deficiency issued. Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to Assistant Administrator, Ahmad Abdallatef who arrived in the middle of the tour.the state’s words, verbatim · CDSS document, Dec 4, 2024

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, 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 27, 2024

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, Marybelle Barnes 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 Nick's Maple Home II, Residential Care Facility for the Elderly, (RCFE) unannounced to conduct an Annual Inspection. LPA was greeted by Najeh Hamed, Administrator. LPA stated the purpose of the visit and was grated entry inside the facility. LPA was also greeted by Staff Member, Maribel Barnes, Caregiver/Staff member also present during visit. Administrator reported there are 6 residents in care; as two residents have recently relocated. LPA was accompanied by the Administrator on a tour of the facility to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is approved for 8 residents in care; Six (6) ambulatory and two, (2) non-ambulatory residents. Pathways throughout the facility and the exterior were free of clutter and obstructions. The facility was maintained at 70 degrees in Fahrenheit. Administrator tested both fire and carbon monoxide alarms. Both alarms were observed to be in proper function. LPA observed the facility's two fully charged fire extinguishers - last inspected October 2023. Extra linens and clean towels were observed on the second floor hallway cabinets, sufficient for the number of residents in care. Extra hygiene supplies, toilet paper, hand soap and paper towels were observed secured in a cabinet on first floor near the kitchen. LPA observed resident rooms, each room included a bed/mattress with required linens, sufficient storage for both residents assigned, furniture, lighting and seating. Each resident room appeared orderly. LPA observed sufficient lighting throughout the facility. LPA observed sufficient furniture and adequate seating provided in the living and dining rooms. The hot water temperature tested and observed within regulation. LPA observed posters for resident rights, Long Term Care Ombudsman, theft and loss policy, Administrator Certificates, Resident Roster, LET-US-KNOW, staff schedule, food menu, and Infection Control posted in a prominent area of the facility. Cleaning supplies, toxins, sharps, and other dangerous items were observed in secure areas throughout the facility. The resident's medication records and medications are kept secure in a kitchen cabinet. Resident, Facility and Staff files are kept secure within the same secure cabinet. At approximately, Please see LIC9099-C 10:15am, LPA conducted a walk through of the facility's backyard. LPA observed a leaf blower, (yard tool) placed on the brick ridge. LPA then observed a partially filled gas can sitting on the ground near the shed. At LPA's request, Administrator picked up both items and secured them in the shed during the visit. Food Service: LPA observed a pantry, cabinets and refrigerators well stocked with canned goods, snacks and dry foods in good standing. Fresh fruit was also observed on the dining room table. LPA observed the facility refrigerator stocked with milk, eggs, breakfast foods, water and juices. Sufficient amounts of both perishable and non-perishable food for the number of residents in care. Sufficient dishes, cups, and utensils were also observed and properly stored. Extra and emergency supplies of food, water, batteries, PPE were located secure in the garage. Records: LPA reviewed four resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 1 staff file for First Aid/CPR certification, criminal record clearance, training, and health screenings. Each file was found to have all required licensing documents and in good standing. Based on observations, interviews and record reviews, one deficiencies will be cited per Title 22, California Code of Regulations; to address the yard tool and gas can left accessible. An exit interview was conducted where this report was reviewed, discussed then provided to the facility representative.the state’s words, verbatim · CDSS document, Dec 11, 2023

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, Amber Coleman, (LPA) arrived at Nick’s Maple Home II to conduct an unannounced complaint visit for #56-AS-20231108143629 During visit, LPA observed deficiencies not related to the complaint allegations. Staff informed LPA that Resident #1, (R1) was transported to the hospital on 10/30/23. LPA inquired the status of the incident reports. LPA informed that they would be sent to Community Care Licensing. On 11/9/23, LPA researched Community Care Licensing's Duty Logs to locate the incident report with no success. LPA contacted Administrator, Najeh Hamed to request the Incident Report. Incident report was emailed to LPA dating the occurring incident on 11/1/2023. There is no time stamp on the incident reports indicating the reports were not submitted to the Community Care Licensing Office within the Reporting Requirement Regulations. Based on observations and interviews, a deficiency will be cited per Title 22, California Code of Regulations to address the reporting requirements. An exit interview was conducted. This report was reviewed and discussed, then provided to Administrator.the state’s words, verbatim · CDSS document, Nov 15, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Nov 9, 2023

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.the state’s words, verbatim · CDSS document, Nov 15, 2023

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.

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced case management visit to obtain signatures for an amended report. LPA met with staff, 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, Nov 15, 2023

Allegation investigated: Staff do not ensure that residents have access to food while in care.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Nick's Maple Home II facility unannounced to initiate a complaint allegation into the allegation listed above. LPA was granted entry and met with Caregiver, Marebelle Barnes. LPA introduced self and stated purpose of the visit. Administrator, Ahmad Abdallatef arrived later during the visit. During today's visit, LPA completed a walkthrough of the facility's interior and exterior, conducted staff and resident interviews and a review of resident files. At approximately, 1:25pm LPA walked into the facility's kitchen. LPA observed the facility's refridgerator. Staff opened the refridgerator and freezer doors. LPA observed fresh fruit, juice, water, bread and eggs. LPA observed adequate amounts of food for the number of residents in care. LPA then observed the kitchen pantry cabinets. Each pantry door was equipped with a lock. LPA attempted to open the cabinet doors and observed them to be locked. LPA observed During the walkthrough of the facility's kitchen During staff and resident interviews, it was revealed that the refridgerator is being locked at night, after dinner. The refrigerator is locked to prevent residents access to food planned to be used for future meals. Substantiated LPA discussed the impact of locking the resident's food supply. To prevent resident's access to their food supply is a violation of the regulations. LPA and Administrator discussed the staffing of the facility; in that securing the resident's food supply should not be used as supervision in the evenings. The facility should have staff available to provide supervision of food services during the day and at night. LPA and Administrator discussed methods of staffing to provide additional supervision in the evenings. LPA requested the Administrator unlock the pantry doors during the visit. LPA did observe Administrator unlock the pantry doors to give residents in care access to the food supply. Additionally, LPA observed fresh fruits on the resident dining table. Staff report the fruits is made available to residents as a snack. Based on observations and interviews with residents and staff, we have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and provided to the facility representative. Please see LIC 9099D.the state’s words, verbatim · CDSS document, Nov 3, 2023 · control 56-AS-20231101125452

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80072(a)(3) · Plan of correction due date: Nov 6, 2023

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.the state’s words, verbatim · CDSS document, Nov 3, 2023

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.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, Amber Coleman, (LPA) arrived at Nick’s Maple Home II to conduct an unannounced complaint visit for #56-AS-20230426113048 & 56-AS-20231101125452 During visit, LPA observed deficiencies not related to the complaint allegations. LPA reviewed two, (2) resident files. 2 out of 2 resident files were incomplete. LPA observed that R1’s Physician’s Report was out of date. LPA observed that the date printed on the Physician’s Report was 1/7/2021. R2's resident file was missing the Physician's Report. Administrator agreed to contact R2's Medical Offices to have the Physician's Report completed. At approximately, 1:35pm LPA walked through the facility's backyard. Upon exiting the facility through the sliding doors, laid a an orange water hose. LPA observed a shovel and a rake leaned up against the side wall of the facility. LPA observed another rake leaned up against the perimeter gate. Along the left side pathway of the facility is a shed. The shed door was observed ajar. Inside the shed were wheelchairs, walkers, unidentifiable medical equipment, and two, (2) bottles of chemicals/toxins. LPA walked to the right exterior pathway where another shed is located. The door to this shed was open. Inside the shed were large numbers of yard tools, power tools, chemicals and sharp objects. Leaned up against the shed were additional yard tools. LPA observed 2 parked vehicles in the backyard. A blue colored sedan along with a white pick up truck. The 2 vehicles obstruct the evacuation route of the facility. Residents in care often utilize walkers and wheelchairs. The two vehicles obstruct the pathway; preventing residents from getting wheelchairs or walkers through the walkway. LPA discussed observations and concerns with Administrator Ahmad Abdallatef, who coordinated with staff to make the corrections during the visit. Administrator rolled up the water hose, secured all of the yard tools moving them to the sheds. The sheds were then secured. The two vehicles were also removed from the backyard to unobstruct the pathway out of the facility. At approximately 1:50pm LPA requested the staffing schedule and the food menus as they were not posted. Administrator reported that the facility food menu and staffing schedule would need to be created and submitted to LPA at a later time/date. Based on observations and record reviews, a deficiencies will be cited to address the above-mentioned concerns. Please see attached LIC809-D. An exit interview was conducted, this report was reviewed, discussed, and then provided to the facility Representative.the state’s words, verbatim · CDSS document, Nov 3, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80069(1)(a) · Plan of correction due date: Nov 29, 2023

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.the state’s words, verbatim · CDSS document, Nov 3, 2023

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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR80022(a)(5) · Plan of correction due date: Dec 4, 2023

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.the state’s words, verbatim · CDSS document, Nov 3, 2023

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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80022(9) · Plan of correction due date: Dec 4, 2023

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.the state’s words, verbatim · CDSS document, Nov 3, 2023

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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87309(a) · Plan of correction due date: Dec 8, 2023

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.the state’s words, verbatim · CDSS document, Nov 3, 2023

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.

Allegation investigated: Resident eloped from facility. Staff do not report incidents to appropriate parties. Facility has pests.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at Nick’s Maple Home II to deliver the findings of the complaint. LPA was granted entry and provided space to work. LPA met with staff and discussed the following: It is alleged that R1 eloped from the facility. During staff interviews, LPA discovered that all staff denied that R1 had ever left the facility without notice. The facility Administrator provides transportation to residents. The facility did not have any records reflecting that R1 left the facility without notice or assistance. Also, R1 reported that anytime she leaves the facility, transportation is provided by medical insurance and/or staff of the facility. It is alleged that staff do not report incident to appropriate parties. LPA reviewed facility records, incident reports and resident records and did not observe any indications that Special/Unusual Incident Reports are **Please see LIC9099-C** Unsubstantiated not being filed per regulation. All staff and R1 denied that she left the facility without notice, therefore there is no incident report required to be submitted. All staff deny that incident reports are not being submitted or have any knowledge of incidents going unreported to Community Care Licensing. It is alleged that the facility has pests. LPA completed a walk through of the resident rooms and the interior and exterior of the facility. LPA observed no evidence of a pest problem. While inspecting resident rooms, LPA observed that residents are permitted to have food in their rooms. During staff interviews, LPA learned that the facility maintains a contract with Freedom Pest Extermination. Administrator and Staff members report that the facility is serviced by pest control once a month. LPA was provided an invoice for the pest control’s last visit to the facility. Based on observations, interviews and record reviews, these allegations are 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, this report was reviewed, discussed, and then provided to facility representative.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 56-AS-20230426113048