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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005891
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:43:13 PM

Document Has Been Signed on 12/07/2023 03:43 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:NANTUCKET HOMEFACILITY NUMBER:
306005891
ADMINISTRATOR:CANDIAS, JACOBFACILITY TYPE:
737
ADDRESS:1051 NANTUCKET ST.TELEPHONE:
(562) 267-0102
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 3CENSUS: 3DATE:
12/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Samantha Reyes-Administrator AssistantTIME COMPLETED:
04:02 PM
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form LIC9099-D on 10/19/23. LPA was greeted and granted entry into the facility by Administrator Assistant (ADA) Samantha Reyes. LPA explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 80087(a) pertaining to Buildings and Grounds has been cleared. Licensee repaired the hallway floor. Licensee has complied with the POC.

Licensee has been advised to maintain compliance in all items previously cited.

An exit interview was conducted with Register Behavior Technician Kylie Galicia and a copy of this was provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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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