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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881035
Report Date: 05/01/2023
Date Signed: 02/03/2024 01:42:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
04/26/2023 and conducted by Evaluator Amber Coleman
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230426163659
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
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Michelle Mangoaoang, Staff MemberTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff are not adequately supervising residents while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Nick's Maple Home III unannounced to initiate a complaint investigation into the above listed allegations. LPA met with Staff Member, Michelle Mangaoaong, introduced self and stated purpose of the visit. LPA was granted entry. Staff contacted Administrator Yusef Nofal, who arrived later during LPA's visit.

Today's visit consisted of staff and resident interviews, walk through of facility's physical plant and review of records. It is alleged that facility staff are not adequately supervising resident while in care. According to facility records, there are two staff members providing services to nine residents in care. Staff Member, Michelle Mangaoaong resides on facility property. Administrator, Yusef Nofal reported he a fellow Administrator makes frequent visits to the facility each morning for assistance. Also multiple occasions throughout the week to conduct facility errands such as grocery shopping or provide transportation to residents in care. The facility also has a maintenance staff member for additional support.

Please see LIC9099-C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20230426163659
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 III
FACILITY NUMBER: 361881035
VISIT DATE: 05/01/2023
NARRATIVE
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LPA made multiple attempts to meet and speak with R1. Staff confirmed that R1 relocated to a location that could provide a higher level of care. Reviews of records revealed that the facility provides care to residents that may suffer from memory impairments, history of mental illness and require assistance with medication management. LPA unable to obtain a copy of the Police Report. Reporting Party and Administrator a history of R1 making similar claims, but no evidence could be observed or located.

LPA observed staff present during visit completing tasks such as cleaning and laundry service. Another staff member, was observed returning to facility during visit. According to staff interviews, staff lives on facility grounds. According to resident interviews, staff lives on site. Staff provides assistance with medications, laundry, meal preparations and assistance with activities of daily living throughout the day and night.

Based on information above, the allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Facility Representative and a copy of this report was provided.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 2