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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880833
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:03:45 PM

Document Has Been Signed on 11/15/2023 04:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 IIFACILITY NUMBER:
361880833
ADMINISTRATOR:HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:1065 W HUFF STREETTELEPHONE:
(909) 440-5252
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 8CENSUS: 6DATE:
11/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Marebelle Barnes, Care TIME COMPLETED:
03:46 PM
NARRATIVE
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at Nick’s Maple Home II to conduct an unannounced complaint visit for #56-AS-20231108143629 During visit, LPA observed deficiencies not related to the complaint allegations.

Staff informed LPA that Resident #1, (R1) was transported to the hospital on 10/30/23. LPA inquired the status of the incident reports. LPA informed that they would be sent to Community Care Licensing. On 11/9/23, LPA researched Community Care Licensing's Duty Logs to locate the incident report with no success. LPA contacted Administrator, Najeh Hamed to request the Incident Report. Incident report was emailed to LPA dating the occurring incident on 11/1/2023. There is no time stamp on the incident reports indicating the reports were not submitted to the Community Care Licensing Office within the Reporting Requirement Regulations.

Based on observations and interviews, a deficiency will be cited per Title 22, California Code of Regulations to address the reporting requirements.



An exit interview was conducted. This report was reviewed and discussed, then provided to Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2023 04:03 PM - It Cannot Be Edited


Created By: Amber Coleman On 11/09/2023 at 10:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2023
Section Cited
CCR
87211(a)(2)

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87211 Reporting Requirements - (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences,... which threaten the welfare, safety or health of residents... shall be reported within 24 hours either by telephone or
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Administrator agrees to work with staff to develop a plan to submit Incident Reports to the Community Care Licensing Office within the regulated timeframe. Administrator aggrees to put the plan in writing and submit the plan to the community Care Licensing Office within the folllowing business day.
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facsimile to the licensing agency...
This requirement is not met as evidenced by:
Based on observations and review of records, the Administrator failed to report 2 special/unusual incident reports to the licensing office within the required timeframe.
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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.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Amber Coleman
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
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