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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880833
Report Date: 11/03/2023
Date Signed: 11/03/2023 03:29:08 PM

Substantiated


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
11/01/2023 and conducted by Evaluator Amber Coleman
COMPLAINT CONTROL NUMBER: 56-AS-20231101125452
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: 6DATE:
11/03/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Marebelle Barnes, CaregiverTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff do not ensure that residents have access to food while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Nick's Maple Home II facility unannounced to initiate a complaint allegation into the allegation listed above. LPA was granted entry and met with Caregiver, Marebelle Barnes. LPA introduced self and stated purpose of the visit. Administrator, Ahmad Abdallatef arrived later during the visit.

During today's visit, LPA completed a walkthrough of the facility's interior and exterior, conducted staff and resident interviews and a review of resident files. At approximately, 1:25pm LPA walked into the facility's kitchen. LPA observed the facility's refridgerator. Staff opened the refridgerator and freezer doors. LPA observed fresh fruit, juice, water, bread and eggs. LPA observed adequate amounts of food for the number of residents in care. LPA then observed the kitchen pantry cabinets. Each pantry door was equipped with a lock. LPA attempted to open the cabinet doors and observed them to be locked. LPA observed During the walkthrough of the facility's kitchen During staff and resident interviews, it was revealed that the refridgerator is being locked at night, after dinner. The refrigerator is locked to prevent residents access to food planned to be used for future meals.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
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 3
Control Number 56-AS-20231101125452
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: 11/03/2023
NARRATIVE
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LPA discussed the impact of locking the resident's food supply. To prevent resident's access to their food supply is a violation of the regulations. LPA and Administrator discussed the staffing of the facility; in that securing the resident's food supply should not be used as supervision in the evenings. The facility should have staff available to provide supervision of food services during the day and at night. LPA and Administrator discussed methods of staffing to provide additional supervision in the evenings. LPA requested the Administrator unlock the pantry doors during the visit. LPA did observe Administrator unlock the pantry doors to give residents in care access to the food supply. Additionally, LPA observed fresh fruits on the resident dining table. Staff report the fruits is made available to residents as a snack.

Based on observations and interviews with residents and staff, we have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and provided to the facility representative. Please see LIC 9099D.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20231101125452
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2023
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights - ....each client shall have personal rights which include, but are not limited to, the following:
(3) To be free from corporal or unusual punishment, ...or other actions of a punitive nature, including but not limited tofunctions, including eating...
This requirement was not met as evidenced by:
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Administrator unlocked the facility pantries during the visit and agreed to keep them unlocked and informed staff to keep them unlocked. Administrator agrees to submit a statement of undertaning of the violation and to keep the food supplies unlocked.
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Based on observations and interviews the Administrator prevents residents access to the food supply during the evenings by keeping the pantries and refridgerator locked which poses an immediate Health, Safety and Personal Rights risk to persons 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: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3