Facility Evaluation Report

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.