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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800144
Report Date: 10/12/2021
Date Signed: 10/12/2021 02:09:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210708080559
FACILITY NAME:NICK'S MAPLE HOME LLCFACILITY NUMBER:
361800144
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
735
ADDRESS:9008 S MAPLE AVENUETELEPHONE:
(786) 219-6008
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:22CENSUS: DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Najeh "Nick" Hamed - Licensee/AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
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9
Resident left the facility unassisted
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of deliering findings on a complaint with the above allegations. LPA Colvin met with Licensee/Administrator Najeh "Nick" Hamed and advised them of the purpose of today's inspection. Below is a summary of the findings:

Regarding allegation "Resident left the facility unassisted": LPA Colvin conducted interviews with relevant parties including residents, staff, family members, and other outside individuals. The majority of persons interviewed stated that Resident 1 (R1) never lived at this facility. It was additionally stated in some interviews that R1 was referred to this facility, but due to the facility being at capacity, R1 was not accepted and was admitted to a Room & Board (where R1 was found deceased). There was no evidence provided to suggest that R1 was ever admitted to this facility, and the Licensee had no records available on R1 as they were never a resident. There was not enough evidence available during this investigation to confirm whether or not R1 was a resident at the facility, therefore, the allegation of "Resident left the facility unassisted" is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20210708080559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NICK'S MAPLE HOME LLC
FACILITY NUMBER: 361800144
VISIT DATE: 10/12/2021
NARRATIVE
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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.

LPA Colvin conducted an exit interview with Licensee/Administrator Najeh "Nick" Hamed and provided a copy of the report.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2