306005891-3-12-2025-22-AS-SHAD-DEPNU7-20250312104552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005891
Report Date: 03/12/2025
Date Signed: 03/12/2025 10:46:50 AM

Document Has Been Signed on 03/12/2025 10:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	NANTUCKET HOME		FACILITY NUMBER:	306005891
ADMINISTRATOR/ DIRECTOR:	PUA TATA		FACILITY TYPE:	737
ADDRESS:	1051 NANTUCKET ST.		TELEPHONE:	(562) 267-0102
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY: 3		CENSUS: 2	DATE:	03/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:33 AM
MET WITH:	Ronnie Chua		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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) Ronnie Chua and discussed the purpose of the inspection. Administrator (AD) Pua Tata arrived during the inspection. LPA reviewed Infection Control requirements. At about 8:00AM, 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 detached garage that is used for storage. There is a back yard with a patio cover for the clients. LPA observed 4 care staff and 2 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 105 degrees F in the two bathrooms. 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 laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are not yet past due. At about 9:00AM, LPA reviewed 2 client files and 4 staff files, interviewed 2 clients and 2 staff, inspected medications for 2 clients, and inspected client money and ledgers for 2 clients. CONTINUED

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

Document Has Been Signed on 03/12/2025 10:46 AM - It Cannot Be Edited

Created By: Sean Haddad On 03/12/2025 at 10:29 AM

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: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(k)

Administrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents and admission, the administrator has not completed the 3 hour HIV and 1 hour TB training within the last 2 years, which poses a potential health risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Licensee stated they will have the administrator complete the required HIV/TB training and submit proof to LPA by POC due date.

Type B

Section Cited

CCR

80068(a)

Admission Agreements

(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee did not ensure 1 out of 2 clients had completed admission agreements, which poses a potential personal rights risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Licensee stated they will ensure both clients have completed admission agreements and submit both admission agreements to LPA by POC due date.

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: 03/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 03/12/2025 10:46 AM - It Cannot Be Edited

Created By: Sean Haddad On 03/12/2025 at 10:29 AM

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: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(c)(4)

Client Medical Assessments

(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee did not ensure 1 out of 2 clients had physician's reports which included a determination of their ambulatory status, which poses a potential safety risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Licensee stated they will ensure all clients have completed physician's reports and submit both physician's reports to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: 03/12/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the inspection, LPA and S1 observed the following: based on documents and admission, the administrator has not completed the 3 hour HIV and 1 hour TB training within the last 2 years; based on documents, the licensee did not ensure 1 out of 2 clients had completed admission agreements; and based on documents, the licensee did not ensure 1 out of 2 clients had physician's reports which included a determination of their ambulatory status.

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: 03/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

Page: 6 of 6