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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881035
Report Date: 01/14/2026
Date Signed: 01/14/2026 05:45:00 PM

Document Has Been Signed on 01/14/2026 05:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 IIIFACILITY NUMBER:
361881035
ADMINISTRATOR/
DIRECTOR:		HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:2838 N. IRONWOOD AVETELEPHONE:
(786) 219-6008
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 10CENSUS: 10DATE:
01/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Ahmad Abdallatef, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:55 PM
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On 1/14/2026 Licensing Program Analysts, (LPAs) LaVette Farlow and Michelle Echeverria arrived at the Nick's Maple Home III, unannounced to conduct an Annual Inspection. LPAs was greeted by Caregiver, Michelle Manaoang. LPAs introduced self and stated purpose of the visit and was granted entry. Caregiver Michelle notified Administrator, Ahmad Abdallatef of LPAs arrival. LPAs were provided space to work, and conducted a tour of the facility. Administrator Ahmad, and House Manager Malik Salem arrived later and participate during the inspection.

Facility: The facility is two (2) story home. It home is a 5 bedrooms, 1 of the 5 bedrooms is for staff, a kitchen, two, (2) living room areas, dining room, laundry space, backyard and attached garage. The facility is approved for a capacity of 10. The facility is approved ten (10) of which eight (8) ambulatory two (2) non-ambulatory. The current census is ten (10). There is a hospice waiver in place approval for 2. The temperature throughout the facility is a comfortable 76 degrees. The facility is equipped with operational smoke alarms, and carbon monoxide detectors. LPA observed two fully charged fire extinguishers. Each one was last inspected October 7, 2025. The facility water was tested and the temperature ranged from 127.9, and 122.3, a technical violation issued.

Resident Rooms - Each resident bedroom can accommodate any ambulatory resident. All resident bedrooms were adequately furnished with bed, storage space, chairs, and lighting.

Please see LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/14/2026
NARRATIVE
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Bathrooms: All bathrooms contained working appliances and adequate hand hygiene and paper supplies. Hand rails and non-slip grip materials were observed near toilets and in showers/tubs.

Kitchen - The facility contained an adequate supply of dry goods, canned goods and non-perishable items for the amount of residents in care. Sharp objects, chemicals/cleaning supplies are maintained and secured in a cabinet near the front door. Additional food items such as milk, bread, eggs, fresh fruits, condiments, cheese, cookies, ice cream, cereals and meats were located in the kitchen refrigerator and two deep freezers in the attached garage.

Personnel Records- LPAs reviewed two (2) employees record for first aid certification, finger print clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights and training verification, and current administrator certification. LPAs observed that 1 out of 2 staff records were incomplete and missing a Health screening and TB test results. A Deficiency cited.

Resident Records- LPAs reviewed seven (7) resident files for: admission agreements, medical assessments and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPAs observed that the Administrator did not have a physicians' report for one resident who was admitted since November 2025. A deficiency cited. LPAs observed resident Admission report were missing signatures, and some were printed double sided and with white out, and the appraisal and pre-appraisal were missing signatures. A deficiency cite. LPAs observed a first aid kit, and it was complete.

Backyard/Outdoor Space: LPAs observed the facility patio, with a shaded area with chairs. The Laundry space was observed en route to the attached garage. It contained operable washer and dryer.

***Continued LIC809C***

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/14/2026
NARRATIVE
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LPAs observed the following posters posted throughout the facility: Resident Roster, Resident Rights, Facility License, Emergency/Disaster Plan, Emergency Contact information, Long Term Care Ombudsman, Infection Control and If you see something-say something.

Based on the information observations and review of records during this visit today one technical violation and three deficiencies were cited per Title 22, Division 6 of The California Code of Regulations. The report LIC809, LIC809C, LIC809D, and appeal rights were reviewed and a copy provided to Administrator Ahmad Abdallatef.

NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2026 05:45 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/14/2026 at 05:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NICK'S MAPLE HOME III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in 1 out of 2 staff by not ensuring the staff had a health screening and TB test results maintain in staff file which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2026
Plan of Correction
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Administrator agreed to review, complete and maintain a health screen and TB test results in all staff personnel file. Administrator will complete a statement of understanding for the regulation cited and provide proof of health screening and TB test results by POC due date to LPA.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in by not ensuring all residents file were maintain with a appraisal, pre-admission appraisal report, or ensuring all records are error free and the use of white out does not appear on resident records which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2026
Plan of Correction
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Administrator agrees to review, complete and maintain all residents file with a appraisal, pre-admission appraisal report without the use of white out on the documents. Administrator will submit a statement of understanding with the proof of correction by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2026 05:45 PM - It Cannot Be Edited


Created By: Lavette Farlow On 01/14/2026 at 05:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NICK'S MAPLE HOME III
FACILITY NUMBER: 361881035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in by not ensuring prior to admission and acceptance they have a completed LIC602 report for residents ready for review and in residents file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
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Administrator stated they have the report and will email it to LPA by 1/16/2026. Administrator agrees to review and update all residents file.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2026


LIC809 (FAS) - (06/04)
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