361881035-8-7-2025-56-AS-NBRN-DP8RJ9-20251210120334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881035
Report Date: 08/07/2025
Date Signed: 08/07/2025 03:48:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
08/01/2025 and conducted by Evaluator Lavette Farlow

COMPLAINT CONTROL NUMBER: 56-AS-20250801122654

FACILITY NAME:	NICK'S MAPLE HOME III		FACILITY NUMBER:	361881035
ADMINISTRATOR:	HAMED, NAJEH		FACILITY TYPE:	740
ADDRESS:	2838 N. IRONWOOD AVE		TELEPHONE:	(786) 219-6008
CITY:	RIALTO	STATE: CA	ZIP CODE:	92377
CAPACITY:	10	CENSUS: 10	DATE:	08/07/2025
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Yousef Nofal, Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff are not providing adequate food service
Staff do not keep kitchen clean and orderly

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaVette Farlow arrived to facility to conduct a complaint investigation regarding the above allegations. LPA Farlow was greeted and granted entrance into the home by Caregiver, Michelle Mangaong. LPA Farlow asked Caregiver Michelle to notify the administrator of my arrival. LPA met with Administrator, Yousef Nofal and Ahmad Abdallatef explained the elements of the complaint.

The allegation is staff are not providing adequate food service.

LPA Farlow investigation consist of an tour of the facility, record review, interviews with residents, and staff. LPA interviewed seven (7) residents. Seven (7) out of seven (7) residents stated staff have adequate food service. Residents stated the facility has plenty of food for residents in care. Seven (7) out of seven (7) residents stated staff provide plenty of food and a variety of different meals to eat. LPA interviewed three (3) out of three (3) staff. The results from the interview with the three staff revealed that staff provide adequate food service for resident in care. Staff stated we conduct a weekly grocery store run. LPA observed S2 cooking in the kitchen using gloves and the food was covered. During the visit LPA observed another staff delivering grocery to the facility. ***continued on LIC 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

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-20250801122654

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: NICK'S MAPLE HOME III	FACILITY NUMBER: 361881035
	VISIT DATE: 08/07/2025

NARRATIVE

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The second allegation is staff do not keep kitchen clean and orderly.

LPA interviewed seven (7) out of seven (7) residents and all the residents stated S2 is a hard worker and does a very good job at keeping the kitchen clean and in order. Upon LPA's arrival I observed S2 preparing a meal. LPA observed the food was covered, the kitchen was clean and orderly. LPA did not observed any flies on the food or on the eating utensils. LPA interviewed three (3) out of three staff. Three (3) out of three (3) staff stated the facility keeps the kitchen clean and in order.

Based on information above, the allegations is 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 violations did or did not occur.

An exit interview was conducted with Yousef Nofal and Ahmad Abdallatef, Adminsitrator and a copy of this report LIC9099, and LIC9099C was provided at the conclusion of the visit.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC9099 (FAS) - (06/04)

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