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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881035
Report Date: 05/18/2026
Date Signed: 05/18/2026 12:14:37 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
03/04/2026 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20260304150013
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:
05/18/2026
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Sharef "Sean" Awad, Caregiver and Hamza Abuawad, AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Illegal eviction
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, Sharef "Sean" Awad. LPA Farlow asked Caregiver Sean to notify the administrator of my arrival. LPA spoke to Administrator, Ahmad Abdallatef and Yusef Nofal via phone and explained the purpose of the visit and the complaint elements.

During the course of the investigation the LPA conducted interviews with resident, staff and relevant parties. LPA reviewed records, obtained copies of documentation from residents.

The allegation is the facility conducted an illegal eviction. LPA interviewed staff, resident, and relevant parties. LPA interviews revealed that R1 was not given a 30 day notice advising R1 of the move. R1's Conservator or Social Worker were not aware of the move and was not notified of a need to move. LPA interview with staff revealed that the facility moved the wrong resident and there are two (2) residents with similar names.
***continued on LIC 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
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-20260304150013
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: 05/18/2026
NARRATIVE
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LPA was informed that R1 was returned to the facility but has since moved to another facility. Due to the eviction procedure not being followed and proper notification was not provided to R1 or his responsible parties, such as his conservator or social worker the allegation is SUBSTANTIATED. The illegal eviction procedure was met by not following the Health and Safety standard per regulation 1569.682 (2)(A), Eviction Procedures.

Based on the aforementioned, we have SUBSTANTIATED the complaint allegation as valid. A violation has occurred based on the preponderance of available evidence. A copy of this report LIC9099, LIC9099C, LIC9099D, and appeal rights are being reviewed and provided to the Administrator, Hamza Abuawad.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20260304150013
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: 05/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2026
Section Cited
HSC
1569.682(2)(A)
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1569.682(2)(A) resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction.
(A) ...reason for the eviction, with specific facts...determination of the date, place, witnesses... concerning the reasons.
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Administrator agrees to review and complete a statement of understanding of the regulation cited and submit a copy to LPA acknowledging te regulation violated.
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This requirement was not met based on interviews conducted. The licensee did not comply with the section cited above by not providing R1 or R1's responsible parties with notification of the move or a reason for the move. R1 nor R1's responsible did not receive a 30 day notice which pose a health and safe risk and violates R1's personal rights.
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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: 05/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3