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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880833
Report Date: 12/04/2024
Date Signed: 12/04/2024 02:19:29 PM

Unsubstantiated


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
09/18/2024 and conducted by Evaluator Lavette Farlow
COMPLAINT CONTROL NUMBER: 56-AS-20240918095317
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: 4DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ahmad Abdallatef, AdministratorTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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9
Resident is being held at the facility against their will.
Staff is not allowing resident access to resident's funds.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to the facility to conclude the investigation of and deliver findings to the above-mentioned complaint. LPA met with Administrator, Ahmad Abdallatef, who was informed of the reason for today's visit. The investigation consisted of interviews with clients, witnesses and staff.

It is alleged that resident is being held at the facility against their will. Interview with resident 1 (R1) stated that staff does not allow R1 to attend church or go to the bank. LPAs interviewed five (5) out of five (5) residents in care and three (3) out of four (4) residents stated they are able to leave whenever they want. One resident (R4) refused to answer. Interview with staff revealed that residents are allowed leave the facility, they take the resident on outing and they are not being held against their will. Interview with witnesses (W1) and (W2) revealed that R1 receives visits and goes on outing with family.

It is alleged that staff is not allowing resident access to resident’s funds. Interview with R1 stated that staff did not take them to the bank to get their funds. Interview with staff 1 (S1) revealed that the facility does not handle any resident in care funds. All monies are either issued on a debit card or the resident responsible party handles their funds. Interviews with five (5) out of five (5) residents revealed the three residents stated they have full access to the funds. One (1) resident refused to respond. Interviews with W1 and W2 revealed that the family handles funds for R1.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
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-20240918095317
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 II
FACILITY NUMBER: 361880833
VISIT DATE: 12/04/2024
NARRATIVE
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Based on interviews the above allegations is Unsubstantiated. A finding that complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and this report was discussed and provided to Ahmad Abdallatef, Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2