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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880833
Report Date: 12/12/2024
Date Signed: 12/12/2024 11:13:44 AM

Document Has Been Signed on 12/12/2024 11:13 AM - 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/
DIRECTOR:		HAMED, NAJEHFACILITY TYPE:
740
ADDRESS:1065 W HUFF STREETTELEPHONE:
(909) 440-5252
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 8CENSUS: 7DATE:
12/12/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Ahmad Abdallatef- Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:26 AM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced POC visit in order to inspect for corrected deficiencies cited on 12/04/24. LPA introduced self and was granted entrance by resident 1 (R1). LPA called the Administrator Najeh Hamed and informed him of the purpose of the visit.

During today's visit, LPA made interviews, physical observations of the facility and reviewed records. Deficiency 87411(a) has not been cleared. LPA observed upon arriving that the facility was not fully staffed with staff present at all times which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty issued.

An exit interview was conducted and discussed, and copies of this report, LIC809, LIC 421FC, and Appeal Rights were provided to Assistant Administrator, Ahmad Abdallatef.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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