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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601056
Report Date: 01/15/2025
Date Signed: 03/05/2025 09:52:00 AM

Document Has Been Signed on 03/05/2025 09:52 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:NABAUNS MANOR, INC.FACILITY NUMBER:
198601056
ADMINISTRATOR/
DIRECTOR:		INGRID CHAMBERLAINFACILITY TYPE:
735
ADDRESS:312 WEST 109TH STREETTELEPHONE:
(323) 455-1581
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 6CENSUS: 2DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Ingrid Chamberlain, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 01/15/2024 Licensing Program Analyst (LPA), Yolanda Rosser conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA, Rosser verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. Census 2.

LPA, Rosser met with the Administrator Ingrid Chamberlain. LPA, Rosser explained the purpose of today’s visit. The facility is licensed to operate for six (6) ambulatory and non ambulatory adults ages 18 through 59 years of age.



The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client's rooms, one (1) common bathroom, a living area, a dining area, a kitchen, and outside patio area. LPA toured the physical plant. There were no bodies of water or obstruction on the premises. All rooms Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. There was adequate supplies and extra linen and towels.

There was adequate perishable for at least 3 days and at least a 7 day supply of non-perishables. Continued on LIC 809C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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: NABAUNS MANOR, INC.
FACILITY NUMBER: 198601056
VISIT DATE: 01/15/2025
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Bed linens, comforters, and bath towels were adequately stocked at the visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature was maintained in the facility.

No deficiencies were cited during this inspection visit.


Personnel Records - Training - records were reviewed.

An exit interview was conducted, and a copy of this report was provided to Ingrid Chamberlain, Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Yolanda Rosser
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2025
LIC809 (FAS) - (06/04)
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