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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005891
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:37:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
10/17/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241017091047
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: 2DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Pua Tata, Program Manager (via telephone)
Andrea Starling, Lead Direct Service Provider		TIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
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7
8
9
Facility staff did not follow restricted health condition requirements for clients
Facility staff did not ensure clients received medical care
Facility does not have an infection control plan
Facility is not reporting incidents
Facility is in disrepair
INVESTIGATION FINDINGS:
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3
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5
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8
9
10
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12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation into the allegations listed above. LPA was greeted and granted entry by the facility's Direct Service Providers after introducing himself and stating the purpose of the visit. Program Manager Pua Tatai was notified of the visit via telephone, presented with the allegations as well as with the findings. Lead Direct Service Provider Andrea Starling was present and assisted with the visit.

An initial complaint investigation visit took place on October 21, 2024. During that visit, LPA accompanied by staff conducted a tour of the facility's physical plant. LPA requested and reviewed client records for the two currently admitted clients. The contents of the facility's first aid kit were reviewed along with the contents of the medication cart in use by staff.

CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
10/17/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241017091047

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: 2DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Pua Tata, Program Manager (via telephone)
Andrea Starling, Lead Direct Service Provider		TIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have a qualified administrator

Facility does not have a complete first aid kit

Medications are not properly labeled
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation into the allegations listed above. LPA was greeted and granted entry by the facility's Direct Service Providers after introducing himself and stating the purpose of the visit. Program Manager Pua Tatai was notified of the visit via telephone, presented with the allegations as well as with the findings. Lead Direct Service Provider Andrea Starling was present and assisted with the visit.

An initial complaint investigation visit took place on October 21, 2024. During that visit, LPA accompanied by staff conducted a tour of the facility's physical plant. LPA requested and reviewed client records for the two currently admitted clients. The contents of the facility's first aid kit were reviewed along with the contents of the medication cart in use by staff.

CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 22-AS-20241017091047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NANTUCKET HOME
FACILITY NUMBER: 306005891
VISIT DATE: 01/15/2025
NARRATIVE
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5
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7
8
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22
23
24
25
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27
28
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30
31
32
CONTINUED FROM FORM LIC9099-A
During the present visit, LPA requested additional documentation including the facility's infection control plan, contraint use log, restraint debriefing forms, serious incident reports as well as the client records for one resident discharged in 2024. Additional staff interviews conducted.

Regarding the allegation that Facility does not have a qualified administrator, the following has been concluded: Upon the termination of former administrator Jacob Candias, a replacement was named in the person of George Aliimatafitafi, designated at the time as an administrator-in-training. Mr. Aliimatafitafi is indicated by current staff to have been terminated for failure to meet with the minimum requirements per Regional Center Requirements as they were not in possession of a Residential Services Orientation with either the Regional Center of Orange County or Los Angeles County. Mr. Aliimatafitafi was however verified to have been in possession of a valid Adult Residential Facility Administrator certificate valid from May 9, 2024 as well as to have been a Registered Behavior Technician. The current administrator is stated to be Ronnie Chua. Minimum requirements for Mr. Chua also verified during the present visit. It is therefore confirmed that the facility's administrator met Title 22 qualification requirements to act as an Enhanced Behavioral Support Home administrator.

Regarding the allegation that Facility does not have a complete first aid kit, the following has been concluded: Upon review conducted by LPA during the initial complaint investigation visit, the first aid kit present inside the medication cart includes Emergency First Aid guide 2022 Edition, Dressing pads and gauze, Scissors, Tweezers, Wrapping bandages, Antiseptic towelettes. All required elements are therefore verified to have been present.

Regarding the allegation that Medications are not properly labeled, the following has been concluded: Based on a complete review of the contents of the medication cart, all prescribed and PRN medications for both clients in care at the time of both visits are adequately labelled by their respective pharmacy. Photographs on file.

Based on the evidence gathered during the investigation, the three allegations listed above are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid; there is not a preponderance of evidence to prove that the alleged violations did or did not occur.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 22-AS-20241017091047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NANTUCKET HOME
FACILITY NUMBER: 306005891
VISIT DATE: 01/15/2025
NARRATIVE
1
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3
4
5
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7
8
9
10
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12
13
14
15
16
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32
CONTINUED FROM FORM LIC9099
During the present visit, LPA requested additional documentation including the facility's infection control plan, constraint use log, restraint debriefing forms, serious incident reports as well as the client records for one client discharged in 2024. Additional staff interviews conducted.

Regarding the allegation that Facility staff did not follow restricted health condition requirements for clients, the following has been concluded: Restricted health conditions plan for one former resident for diabetes mellitus and one current resident for asthma and use of an inhaler were reviewed during the visit and verified to have been in place at the time of the semi-annual visit. No plan could be reviewed for the use of a CPAP machine as stated in the DDS report.

Regarding the allegation that Facility staff did not ensure clients received medical care, the following has been concluded: Based on records reviewed during the investigation, it was confirmed that one of the clients did not receive the allotted two hours of dietician care stated in their plan of care for the months of August and September 2024. Current outside provider notes were reviewed during the follow-up visit and confirmed that the specialized care had been received every month thereafter.

Regarding the allegation that Facility does not have an infection control plan, the following has been concluded: No available infection control plan could be reviewed during the semi-annual visit conducted by the Department of Developmental Services. The initial complaint investigation visit also found no infection control plan in place as of October 21, 2024. Facility staff provided LPA with a completed plan dated November 15, 2024 during the follow-up visit. It is therefore confirmed that the facility did not have a current Infection Control Plan in place prior to November 2024.

Regarding the allegation that Facility is not reporting incidents, the following has been concluded: Based on a review of submitted Serious Incident Reports, it was determined that at least one instance of constraint use occurring on April 6, 2024 had not been reported to the Department as required by Title 22 regulations. Constraint use logs were reviewed in addition to current Serious Incident Reports. Based on that review, all current incidents appear to have been reported adequately thereafter.

CONTINUED ON FORM LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 22-AS-20241017091047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: NANTUCKET HOME
FACILITY NUMBER: 306005891
VISIT DATE: 01/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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20
21
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30
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32
CONTINUED FROM LIC9099-C

Regarding the allegation that Facility is in disrepair, the following has been concluded: Tour of the facility's physical plant were conducted during both the initial and the follow-up visit. During both instances, it was determined that window screens on one of the bedrooms' windows had been damaged during a client's behavior episode and needed to either be repaired or replaced. A repair was conducted between the initial and the follow-up visit, however a more recent episode damaged the screen again, which is currently pending replacement.

As a result of this investigation, the five allegations listed above are found to have been Substantiated, meaning that the preponderance of evidence standard has been met. Deficiencies are being cited on the attached LIC 9099D forms. An exit interview was conducted and a copy of this report was provided to facility along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 22-AS-20241017091047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NANTUCKET HOME
FACILITY NUMBER: 306005891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2025
Section Cited
CCR
80092.1(m)
1
2
3
4
5
6
7
Per CCR Section 80092.1 on General Requirements for Restricted Health Conditions: "The licensee of an ARF shall develop and maintain (...) a Restricted Health Condition Care Plan as specified in Section 80092.2". This requirement is not met as evidenced by:
1
2
3
4
5
6
7
At the time of the follow-up visit, both clients in care are in compliance as one client does not have a restricted health conditions, and plans are confirmed to be in place for the other client's asthma and use of an inhaler.
Deficiency cleared.
8
9
10
11
12
13
14
Based on records review, client records for a discharged client did not include a plan for each of their restricted health conditions at the time of discharge. This constitutes a potential risk to the health, safety and personal rights of individuals in care.
8
9
10
11
12
13
14
Type B
01/16/2025
Section Cited
CCR
80075(a)
1
2
3
4
5
6
7
Per CCR Section 80075(a) on Health Related Services: "The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services".This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Current clients records have been reviewed. Both clients confirmed to have received adequate medical care per their respective plans of care.
Deficiency cleared.
8
9
10
11
12
13
14
Based on client records reviewed, at least one client did not receive the dietician care stated in their plan of care in August and September 2024. This constitutes a potential risk to the health, safety and personal rights of individuals in care.
8
9
10
11
12
13
14
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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 22-AS-20241017091047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NANTUCKET HOME
FACILITY NUMBER: 306005891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2025
Section Cited
CCR
85022(a)(1)
1
2
3
4
5
6
7
Per CCR Section 85022(a)(1) on the Plan of Operation: "The plan of operation and related materials shall contain the Infection Control Plan pursuant to Section 85095.5(c)."
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Infection Control Plan of care is currently in place as of November 15, 2024. Facility is presently in compliance, deficiency cleared.
8
9
10
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12
13
14
Based on records reviewed during the investigation, it was confirmed that there was no Infection Control Plan in place prior to November 15, 2024. This consitutes a potential risk to the health, safety and personal rights of individuals in care.
8
9
10
11
12
13
14
Type B
01/16/2025
Section Cited
CCR
85161(b)
1
2
3
4
5
6
7
Per CCR Section 85161(b) on Emergency Intervention Documentation and Reporting Requirements: "(b) Each use of manual restraint or seclusion shall be reported to the Department in writing no later than the next business day". This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Constraints log and incident reports verified for the second half of 2024 and the beginning of 2025. All uses of manual restraint reported as required. Deficiency cleared.
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9
10
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12
13
14
Based on records reviewed, no evidence of a report for a use of constraints dated April 6, 2024 could be found in the Serious Incidents Reports submitted to the Department. This constitutes a potential risk to the health, safety and personal rights of individuals in care.
8
9
10
11
12
13
14
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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 22-AS-20241017091047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NANTUCKET HOME
FACILITY NUMBER: 306005891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
80087(a)
1
2
3
4
5
6
7
Per CCR 80087(a) regarding Buildings and Grounds: "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 is not met as evidenced by:
1
2
3
4
5
6
7
Licensee has already submitted a work order for the repair of the window screen. Repairs will be conducted, documentation to be provided to LPA upon completion, prior to the plan of corrections due date.
8
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14
Based on observation made during tours of the physical plant, two window screens were observed to have been damaged and did not fit adequately to the window frame.
8
9
10
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12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8