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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005891
Report Date: 10/24/2024
Date Signed: 10/24/2024 01:51:45 PM

Document Has Been Signed on 10/24/2024 01:51 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/
DIRECTOR:		CANDIAS, JACOBFACILITY TYPE:
737
ADDRESS:1051 NANTUCKET ST.TELEPHONE:
(562) 267-0102
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 3CENSUS: 2DATE:
10/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:George AliimatafitafiTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20241021164029. LPA met with Administrator (AD) George Aliimatafitafi and explained the reason for today’s inspection.

During the course of the investigation, LPA inspected the facility, interviewed AD, Program Manager (PM) Pua Tata, clients, and staff, and obtained and reviewed copies of the client roster, staff roster, an email dated October 23, 2024, regarding AD’s purchasing card, the facility’s menus for the past year, the facility’s monthly budget, and the facility’s grocery bills for 2024.

LPA interviewed two clients and four staff and obtained information that the facility recently ran out of specific food items, such as cereal and tortillas, and that the menu was not followed due to lack of specific ingredients. LPA interviewed AD and PM who denied this, but stated that due to recent staffing changes, the process for purchasing groceries changed for approximately the last two months because AD did not have a purchasing card to purchase groceries, but the issue has now been resolved. LPA reviewed an email dated October 23, 2024, regarding AD’s purchasing card which corroborated that the issue with AD’s purchasing card has now been resolved. LPA reviewed the facility’s menus for the past year which did not document any of the changes to the menu that were made due to a lack of ingredients.

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: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 10/24/2024 01:51 PM - It Cannot Be Edited


Created By: Sean Haddad On 10/24/2024 at 01:44 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: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2024
Section Cited
CCR
80076(a)(5)

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80076 Food Services (a)… (5) Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days… This requirement was not met as evidenced by:
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Licensee stated that they are going to go back to the old process for purchasing food where the purchasing card is kept at the facility and train staff to document changes to the menu and will submit proof to LPA by POC due date.
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Based on interviews and documents, the licensee did not follow the menu due to a lack of ingredients and did not make changes to the menu as required, which poses a potential health 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: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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