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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881035
Report Date: 05/01/2023
Date Signed: 05/04/2023 02:33:27 PM

Document Has Been Signed on 05/04/2023 02:33 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: 9DATE:
05/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Yusef Nofal, AdminsitratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Nick's Maple Home III to conduct an unannounced complaint visit for 56-AS-20230426163659. During visit, LPA observed deficiencies not related to the complaint allegations.

At approximately 2:17pm, upon arrival to the facility, LPA observed an individual inside the facility's attached garage. LPA introduced self and stated purpose of the visit. The individual identified themselves as Amir Mangaoang. LPA was informed that Amir works at the facility as a handy man. During, the visit, LPA completed a walkthrough of the facility and completed a record review. LPA observed Amir Mangoaoang did not have a fingerprint clearance. This poses an immediate health and safety risk to residents in care. LPA also observed a window ajar on the second floor of the facility. The window was observed did not have a screen on it. Staff informed LPA, the room belongs to a resident in care. The screen was removed by a resident in care during a behavioral episode. This poses an immediate health and safety risk to residents in care.

At approximately, 2:25pm LPA walked through the facility's backyard and observed a broken window on the facility's second floor. The glass of the window has several was cracked in serval places. Each crack in the window leads to a small whole in the center.

Based on observations and interviews, two (2) deficiencies are being issues to address the above concerns. A Civil Penalty was assessed on 5/1/2023. Refer to LIC809-D for deficiencies cited. A copy of this report along with appeal rights are being reviewed with and provided to the facility representative. ** A Civil Penalty assessment accompanies the deficiency.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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 05/04/2023 02:33 PM - It Cannot Be Edited


Created By: Amber Coleman On 05/01/2023 at 04:04 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: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2023
Section Cited
CCR
80019(e)(1)

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800918 Criminal Record Clearence
(e) All individuals subject to a criminal record review..."
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
The requirement is not met as evidenced by:
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Licensee/Administrator will have Amir Mangaoang leave the facility premises immediately until a criminal record clearence can be obatined.
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Based on observation, record reviews and interviews the licensee did not ensure all staff had a criminal records clearence to be employed at the facility which poses an immediate Health and Safety to risk to persons in care.
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Type B
05/31/2023
Section Cited
HSC87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors
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Licensee/Administrator will have the screen replaced on the window of the resident's room. As well as have the broken window fixed within 30 days.
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This requirement was not met as evidenced by:
Based on observation, record reviews and interviews the licensee did not ensure facility was in good repair which poses an a potential Health and Safety to risk to persons 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: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
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