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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881035
Report Date: 07/22/2022
Date Signed: 08/09/2022 11:51:02 AM

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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2022 and conducted by Evaluator Bernadette Allen
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220719175540
FACILITY NAME:NICK'S MAPLE HOME IIIFACILITY NUMBER:
361881035
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:2838 N. IRONWOOD AVETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY:10CENSUS: 10DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH: Ahmad Abdallate-AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Medications are not properly stored.
INVESTIGATION FINDINGS:
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LPA Bernadette Allen arrived at this facility to deliver findings on the above allegation. Upon arrival LPA met with care giver Michelle Mangaoang,

During today’s visit LPA, Allen requested and reviewed the resident’s medications. Based on LPA’s review there were no discrepancies observed with the medications. They were properly stored (being in the original package and labeled with each client’s name on packaging which were stored in a cabinet in the kitchen area locked/and secured from residents. Therefore, the allegation that the medication is not properly stored is UNSUBSTANTIATED.

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, therefore the allegation is Unsubstantiated.
An exit interview where this report was discussed with the staff and a copy of this report was provided to Michelle Mangaoang, at the conclusion of this investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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 56-AS-20220719175540
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
, CA 92507

FACILITY NAME: NICK'S MAPLE HOME III
FACILITY NUMBER: 361881035
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited
HSC
87465(h)1-6(A-F)
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The administrator will ensure that all medications are stored and secured properly at all times by providing additional training to the staff.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2