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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881035
Report Date: 04/21/2025
Date Signed: 04/21/2025 12:34:55 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
01/18/2024 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20240118124025
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:
04/21/2025
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Ahmad Abdallatef, AdministratorTIME COMPLETED:
12:43 PM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Ahmad Abdallatef, Administrator and explained the purpose of the visit. The investigation was conducted by Department staff which consisted of staff interviews, resident interviews and document review.

Allegation, Facility staff failed to properly supervise resident resulting in resident sustaining burns on chest and hands.

Department staff conducted three (3) staff interviews. Three (3) out of the Three (3) staff stated they were aware that Resident one, R1 had a history of burning himself with cigarettes while smoking. R1 would remove filters from the cigarette and hold the lighted cigarette in hand, burning fingertips and lips. Staff revealed that R1 had a prior incident of burning self, using the stove to light a cigarette.
***Continued on LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
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-20240118124025
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: 04/21/2025
NARRATIVE
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Staff was aware of this incident, and the Licensee did not provide an updated reappraisal or needs and assessment plan to prevent the issue from reoccurring.

Department staff also interviewed four (4) residents. Two (2) out of the four (4) residents indicated they would see R1 smoking cigarettes in the backyard and R1 would burn his fingers while smoking.

R1’s social worker, Witness 1 (W1), Nurse Practitioner, Witness 2 (W2) and social worker manager, Witness 3 (W3) stated they were not aware or informed of R1’s behaviors of burning themselves. The facility never notified any of the witnesses of any incidents.

Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

An exit interview was conducted where this report was discussed and reviewed. A copy of this report LIC9099, LIC9099C, LIC9099D, along with appeal rights are being provided to the Ahmad Abdallatef, Administration.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20240118124025
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: 04/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2025
Section Cited
CCR
87468.2(4)
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87468.2(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee stated to submit photo documentation of all staff reading over section 87468.2 (4) and submitting to LPA Farlow by Plan of Correction (POC) due date.
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Based on interview and record review, the licensee did not comply with the section cited above evidenced by Licensee did not seek proper assistance from the support team to prevent R1 from burning self. Licensee did not follow smoking cessation plan, which imposes 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: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3