361800144-6-2-2023-56-AS-EMAN-CUYT5T-20230823142606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800144
Report Date: 06/02/2023
Date Signed: 06/02/2023 02:03:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
06/01/2023 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230601150022

FACILITY NAME:	NICK'S MAPLE HOME LLC		FACILITY NUMBER:	361800144
ADMINISTRATOR:	HAMED, NAJEH		FACILITY TYPE:	735
ADDRESS:	9008 S MAPLE AVENUE		TELEPHONE:	(786) 219-6008
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	22	CENSUS: 22	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Adam Ahmad		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff handled resident in an inappropriate manner.
Staff threatened resident in care.
Staff allows residents to engage in physical and verbal altercations with resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Adam Ahmad and explained the purpose of the visit. The investigation consisted of staff and resident’s interviews.

First allegation: Staff handled resident in an inappropriate manner.

Regarding the first allegation, Staff handled resident in an inappropriate manner. LPA Guerrero conducted in-person interviews with Resident #1, Resident #2, and Resident #3, who all stated that they have not witnessed or experienced staff handle residents in an inappropriate manner. LPA interviewed Staff #1, Staff #2, and Staff #3 who all stated that they have not witnessed staff member[s] handle residents in an inappropriate manner.

Second allegation: Staff threatened resident in care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230601150022

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NICK'S MAPLE HOME LLC	FACILITY NUMBER: 361800144
	VISIT DATE: 06/02/2023

NARRATIVE

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Regarding the second allegation, Staff threatened resident in care. Regarding the first allegation, Staff handled resident in an inappropriate manner. LPA Guerrero conducted in-person interviews with Resident #1, Resident #2, and Resident #3, all stated that they have not witnessed or experienced threats nor bullying behaviors. Resident #1-3 stated that they feel safe at the facility. LPA interviewed Staff #1, Staff #2, and Staff #3 who all stated that they have not witnessed staff member[s] bully or threat residents while in care.

Third allegation: Staff allows residents to engage in physical and verbal altercations with resident in care.

Regarding the third allegation, Staff allows residents to engage in physical and verbal altercations with resident in care. LPA Guerrero conducted in-person interviews with Resident #1, Resident #2, and Resident #3, all stated that they have not witnessed staff to allow residents to engage in physical or verbal altercations with residents in care. Resident #3 (R3) stated they been living at the facility for eight years (8) and have not witnessed staff to allow residents to engage in verbal or physical altercations with residents. Resident #2 (R2) stated that staff are helpful and have not witnessed any staff members to allow such behaviors at the facility. Due to a lack of information, the above allegations are deemed UNSUBSTANTIATED at this time.

Unsubstantiated; meaning that 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 was discussed and provided to Facility Administrator Adam Ahmad.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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