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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005891
Report Date: 01/08/2025
Date Signed: 01/08/2025 09:36:01 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2024 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241227144938
FACILITY NAME:NANTUCKET HOMEFACILITY NUMBER:
306005891
ADMINISTRATOR:PUA TATAFACILITY TYPE:
737
ADDRESS:1051 NANTUCKET ST.TELEPHONE:
(562) 267-0102
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:3CENSUS: 2DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Laquwia WinstonTIME COMPLETED:
09:55 AM
ALLEGATION(S):
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Facility did not ensure the client was accorded with dignity
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and clients as well as reviewed and obtained pertinent documentation such as Individual Program Plan (IPP). Regarding the allegation that facility did not ensure the client was accorded with dignity, the investigation revealed the following: On 12/22/2024, Client 1 (C1) was engaging in aggressive behavior towards C2. C1 attempted to attack C2 and was blocked by Staff 1 (S1) resulting in C1 escalating aggression and dropping to the ground. S2 tried to prevent client from injuring themselves and in the process the client's shirt was ripped. After the incident the client was assessed to have no injuries. Interview with facility management indicates S2 did not follow facility protocols for crisis or Crisis Prevention Institute (CPI) standards. Three out of three staff present during the incident deny any abusive behavior towards the client and state staff were attempting to get the client under control. CONTINUED ON 9099C DATED 01/08/2024.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20241227144938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/08/2025
NARRATIVE
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One out of two clients state staff treat them good and they have no issues with any staff. C1 indicates abusive behavior from Staff 2. Per Individual Program Plan (IPP) dated 10/09/2024, C1 is diagnosed with Control Disorder, Borderline Personality Disorder, Schizoaffective Disorder and Major Depression. IPP identifies severe behaviors including aggression, self abuse, false statements and property destruction. While the staff attempted to de-escalate the situation, facility crisis and CPI protocols were not followed resulting in client not being afforded dignity at the facility. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241227144938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2025
Section Cited
CCR
80072(a)(1)
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Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
To be accorded dignity in his/her personal relationships with staff and other persons. This req is not met as evidenced by:
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Licensee to conduct an in-service on personal rights and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure C1 was afforded dignity in personal relationships with staff. S2 did not follow facility crisis and CPI protocols. This poses a potential health and safety risk to clients 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3