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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005891
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:35:30 PM

Document Has Been Signed on 10/26/2022 03:35 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:
10/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lupe Santa Cruz, Jacob CandiasTIME COMPLETED:
03:50 PM
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This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on recently reported issues. LPA met with Staff #1 (S1) Lupe Santa Cruz and explained the purpose of the inspection. Administrator (AD) Jacob Candias appeared via telephone.

During the inspection, LPA inspected the facility with S1 and observed the following: at the beginning of the hallway in front of the office, the hardwood flooring is warped, creating small mounds that are a tripping hazard; in the non-ambulatory bathroom, the toilet seat is scratched and a part of the toilet fixture has been detached; and in the living room, the top wooden trim on the fireplace is missing.

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: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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 10/26/2022 03:35 PM - It Cannot Be Edited


Created By: Sean Haddad On 10/26/2022 at 03:30 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: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2022
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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Licensee stated they will repair the hard wood floor, toilet, and fireplace and submit proof to LPA by POC due date.
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Based on observation, the licensee did not ensure the hardwood floor, 1 toilet, and the fire place were safe and in good repair, which poses a potential health and safety risk to persons in care.
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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: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022


LIC809 (FAS) - (06/04)
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