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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005891
Report Date: 03/14/2024
Date Signed: 03/14/2024 04:30:33 PM

Document Has Been Signed on 03/14/2024 04:30 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
CCLD Regional Office, 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:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Cierra TrevinoTIME COMPLETED:
04:45 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Cierra Trevino and discussed the purpose of the inspection. Administrator (AD) Jacob Candias was not present during the inspection.

LPA reviewed Infection Control requirements. At about 2:30PM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure: facility is a 3-bedroom, 2-bathroom, one-story house with a detached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 5 staff and 3 clients present at the facility. Client Bedrooms: the 3 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 110 F in the two client bathrooms, after corrections. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees have not been paid. LPA provided information on how to pay the licensing fees. At about 3:00PM, LPA reviewed 3 client files and 4 staff files, interviewed 2 clients and 3 staff, inspected medications for 3 clients, and inspected client money and ledgers for 3 clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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Document Has Been Signed on 03/14/2024 04:30 PM - It Cannot Be Edited


Created By: Sean Haddad On 03/14/2024 at 04:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: NANTUCKET HOME
FACILITY NUMBER: 306005891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the water temperature in the east client common bathroom tested at 126 degrees F, which poses a potential safety risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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During the inspection, the licensee adjusted the water temperature and LPA confirmed. Licensee stated they will conduct staff training on checking water temperatures and will submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NANTUCKET HOME
FACILITY NUMBER: 306005891
VISIT DATE: 03/14/2024
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During the inspection, LPA and S1 observed the following: the water temperature in the east client common bathroom tested at 126 degrees F. During the inspection, the licensee adjusted the water temperature and LPA confirmed.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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