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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880833
Report Date: 10/30/2023
Date Signed: 02/03/2024 02:18:49 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
COMPLAINT CONTROL NUMBER: 56-AS-20230426113048
FACILITY NAME:NICK'S MAPLE HOME IIFACILITY NUMBER:
361880833
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:1065 W HUFF STREETTELEPHONE:
(909) 440-5252
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY:8CENSUS: 8DATE:
10/30/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Marebelle Barnes, CaregiverTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident eloped from facility.
Staff do not report incidents to appropriate parties.
Facility has pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at Nick’s Maple Home II to deliver the findings of the complaint. LPA was granted entry and provided space to work. LPA met with staff and discussed the following:

It is alleged that R1 eloped from the facility. During staff interviews, LPA discovered that all staff denied that R1 had ever left the facility without notice. The facility Administrator provides transportation to residents. The facility did not have any records reflecting that R1 left the facility without notice or assistance. Also, R1 reported that anytime she leaves the facility, transportation is provided by medical insurance and/or staff of the facility.

It is alleged that staff do not report incident to appropriate parties. LPA reviewed facility records, incident reports and resident records and did not observe any indications that Special/Unusual Incident Reports are
**Please see LIC9099-C**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2023
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-20230426113048
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 II
FACILITY NUMBER: 361880833
VISIT DATE: 10/30/2023
NARRATIVE
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not being filed per regulation. All staff and R1 denied that she left the facility without notice, therefore there is no incident report required to be submitted. All staff deny that incident reports are not being submitted or have any knowledge of incidents going unreported to Community Care Licensing.

It is alleged that the facility has pests. LPA completed a walk through of the resident rooms and the interior and exterior of the facility. LPA observed no evidence of a pest problem. While inspecting resident rooms, LPA observed that residents are permitted to have food in their rooms. During staff interviews, LPA learned that the facility maintains a contract with Freedom Pest Extermination. Administrator and Staff members report that the facility is serviced by pest control once a month. LPA was provided an invoice for the pest control’s last visit to the facility.

Based on observations, interviews and record reviews, these allegations are 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, this report was reviewed, discussed, and then provided to facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2023
LIC9099 (FAS) - (06/04)
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