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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320336
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:55:49 PM

Document Has Been Signed on 01/30/2025 03:55 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:NIC & SON HOMEFACILITY NUMBER:
198320336
ADMINISTRATOR/
DIRECTOR:
NICHOLS, BARBARAFACILITY TYPE:
735
ADDRESS:763 W ATHENS BLVDTELEPHONE:
(323) 900-9106
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY: 4CENSUS: 1DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Barbra Nichols - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:56 PM
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On 01/30/2025 Licensing Program Manager (LPA) Troy Watson conducted an unannounced annual required visit. LPA Troy Watson met with the administrator and the purpose of today’s visit was explained. The facility is licensed for 4 persons with developmental / mentally disabled. Presently, the census was 1 client at the time of this visit, the client at the time of visit was at the day program.

LPA Troy Watson toured the inside and outside of the facility with the Barbra Nichols and (3) client bedrooms were checked. Mattresses and box springs were in good condition, clean and in good repair. Adequate lighting and lamps were present and working. There was plenty of dresser and closet space in each client bedroom. All 5 fire extinguishers were full and currently up to date.

Bed linens, comforters and bath towels were adequately stocked at the time of visit in the closet and in the bedrooms. The bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The bathtub was free of mold/mildew. The water temperature properly measured between 114 F and 117.6 F in the bathroom and in the kitchen.

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: NIC & SON HOME
FACILITY NUMBER: 198320336
VISIT DATE: 01/30/2025
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Evaluation Report continues LIC 809-C

LPA Troy Watson observed the facility clean, sanitary, and appropriately furnished at the time of the visit. The kitchen, and refrigerators was fully stocked with food. The administrator has (5) smoke / carbon monoxide detectors that have been tested and found operational. Toxins and knives were locked and inaccessible to clients. Medications are not presently at the facility because the one client residing there does not take any medication. The patio area was clean and accessible to the client. The first aid kit was checked and fully stocked with a certified manual. LPA reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. Staff and client records were available for immediate review and inspection.

An exit interview was conducted, with the Administrator Barbra Nichols and a copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
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