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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881035
Report Date: 10/22/2024
Date Signed: 10/22/2024 02:21:41 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2024 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20240404104547
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:
10/22/2024
ANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Yusef Nofal-Administrator TIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is financially abusing resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bernadette Allen conducted an in-office visit to deliver findings on the mentioned allegation. LPA Allen met with Yusef Nofal-Administrator who was informed of the findings and signed the report.

The investigation involved interviews with residents and staff, as well as a review of records. The interviews with residents and staff indicated that they have not been financially abused by staff members and that ROG services act as their payee. The facility files reviewed, including Resident 1 (R1), confirmed that ROG services are listed as the residents' payee. LPA attempted to interview R1, but they no longer reside at the facility and could not be contacted.

Based on interviews and evidence gathered during the investigation, the above allegation is found to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Yusef Nofal-Administrator where this report was discussed and provided to at the conclusion of the visit with appeal rights.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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