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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881035
Report Date: 04/25/2025
Date Signed: 04/25/2025 01:27:29 PM

Substantiated


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
04/23/2025 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20250423113821
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: 10DATE:
04/25/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ahmad Abdallatef, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not ensuring that residents are administered their medication(s) as prescribed.
Staff are not providing medical supervision to resident in care as needed.
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, Ahmad Abdallatef and explained the elements of the complaint.

Allegation 1: Staff are not ensuring that residents are administered their medication(s) as prescribed.

Regarding the allegation that Staff are not ensuring that residents are administered their medication(s) as prescribed. LPA interviewed four (4) out of four (4) residents and the interview reveal that staff are assisting residents with medication, however after LPA reviewed and audited the MARS log it was found that 3 out of 3 resdients MARS were missing medications and initial were not completed on the MARS. Also, interview with Reporting party, resident, and facility staff revealed there has been a period were R1 and R2 has been without meication. A deficiency was cited. LPA interviewed two (2) out of two (2) staff and it was reveal the staff did not update the MARS with the new prescription medication and PRN meds.
***continued on LIC 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
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 3
Control Number 56-AS-20250423113821
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: 04/25/2025
NARRATIVE
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Based on the investigation process, and interviews during todays investigation, allegation #1 Staff are not ensuring that residents are administered their medication(s) as prescribed is SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence the standard has been met.

Allegation 2: Staff are not providing medical supervision to resident in care as needed.

LPA interviewed 4 out of 4 residents in care and it was revealed that residents are transported to appointment via facility staff or Uber driver. Residents stated they are notified about appointments via facility staff, or social worker. LPA interview with staff revealed that residents are transport to appointments by facility staff. There was one occasion where R1 missed an appointment due to mis-communication, and or lack of a valid contact number. A deficiency was cited.

Based on the investigation process, and interviews during todays investigation, allegation #2 Staff are not providing medical supervision to resident in care as needed is SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence the standard has been met.

During today’s visit, two (2) deficiencies was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC9099, LIC9099C, LIC9099D, and appeal rights was discussed and a copy provided to Administrator Ahmad Abdallatef, at the end of the visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250423113821
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2025
Section Cited
CCR
80070(a)(10)
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(a) The licensee shall..and current record is maintained in the facility for each client. (10) Record of current medications, including the name of the prescribing physician, and instructions..medications.
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Licensee agrees to update all residents in care MARS sheet, and conduct a training on maintaining medication and dispensing of medication with a signed log sheet for all staff in attendance acknowledging the regualtion and completion of training by POC date to LPA Farlow.
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Based on record review, interviews conducted with residents, staff and reporting party, the licensee did not ensure the resident MARS, is maintained, and medication is dispensed and prescribed by physician orders, which poses an immediate health and safety risk to residents in care.
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Type A
05/02/2025
Section Cited
CCR
85075(b)
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85075(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.
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Licensee agrees to make sure all medical needs are met and appointments are maintained. Licensee will ensure that all appointment center have a valid contact number to reach him or other staff to ensure appointment are met. Licensee agrees to review all regulation related to licensee responsibility as it relate to providing medical and dental assistance to residents in care and provide a written statement acknowledging the understanding the responsibility to residents in care medical needs, by POC date.
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Based on interviews, the licensee did not ensure the resident appointment was maintained by not having a valid contact number on file for residents medical provide, which 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3