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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881035
Report Date: 07/25/2025
Date Signed: 07/25/2025 12:32:26 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
07/23/2025 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20250723152835
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: DATE:
07/25/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Ahmad Abdallatef, Administrator TIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff coerced resident to enroll in alternative insurance plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaVette Farlow arrived to facility to conduct a complaint investigation regarding the above allegation. 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, Ahmad Abdallatef and explained the elements of the complaint.

The allegation is staff coerced resident to enroll in alternative insurance plan.

LPA Farlow investigation consist of an tour of the facility, record review, interviews with residents, and staff. LPA interviewed five (5) residents. Four (4) out of five (5) residents stated staff have not forced or coered them to switch insurance plan. Five (5) out of five (5) residents stated staff assist them with medical appointments. LPA reviewed residents file and observed that residents have varies medication insurance programs. LPA interview with R1 revealed that R1 stated the staff coered R1 to change insurance coverage. LPA interviewed three (3) out of three (3) staff. The results from the interview with the three staff revealed that staff did not coerced resident to enroll in alternative insurance plans. ***continued on LIC 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
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-20250723152835
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: 07/25/2025
NARRATIVE
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Based on information above, the allegation is UNSUBSTANTIATED. 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.

An exit interview was conducted with Michelle Mangaoang, Caregiver 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: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2