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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881035
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:41:13 PM

Document Has Been Signed on 11/09/2022 02:41 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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: 8DATE:
11/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Yusef Nofal, AdministratorTIME COMPLETED:
02:35 PM
NARRATIVE
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LPA Amber Coleman and LPA Anna Bueno conducted an unannounced complaint visit for complaint # 56-AS-20221104151616. During this visit, LPAs observed deficiencies not related to the complaint allegations.

During the visit LPAs completed a walk through the facility and reviewed documentation. During the investigation of records. LPA's observed staff 1 (S1) did not have fingerprint clearance. This poses an immediate health and safety risk to residents in care. LPA's were informed that S1 works at the facility as a handy man. A Civil Penalty of $200 was assessed on 11/9/22. Refer to LIC809-D for deficiencies cited. Other deficiencies observed will be cited at a later time.

Citations may be issued at a later time. A copy of this report was provided to Yusef Noval, Administrator
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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Document Has Been Signed on 11/09/2022 02:30 PM - It Cannot Be Edited


Created By: Amber Coleman On 11/09/2022 at 01:43 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: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2022
Section Cited
CCR
80019(e)(1)

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The nature of the crime including, but not limited to, whether it involved violence or a threat of violence to others.
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Licensee shall removed S1 from the facility immediately.
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This requirement was not met as evidenced by LPA's observed S1 in the garage of the facility. LPA verified that S1 does not have a criminal record exemption. This poses an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


LIC809 (FAS) - (06/04)
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