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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005891
Report Date: 10/23/2025
Date Signed: 10/23/2025 12:51:12 PM

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
10/15/2025 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20251015092302
FACILITY NAME:NANTUCKET HOMEFACILITY NUMBER:
306005891
ADMINISTRATOR:MAFA SETIFACILITY TYPE:
737
ADDRESS:1051 NANTUCKET ST.TELEPHONE:
(562) 267-0102
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:3CENSUS: 2DATE:
10/23/2025
UNANNOUNCEDTIME BEGAN:
07:44 AM
MET WITH:Pua TataTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Facility staff did not properly document manual restraint debriefings
The licensee did not ensure staffing ratios were met
The licensee did not follow the plan of operation
Facility staff are not administering medications as prescribed
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegations. LPA met with Program Manager (PM) Pua Tata, discussed the purpose of the inspection, and explained the allegations.

The investigation into the allegations that facility staff did not properly document manual restraint debriefings, the licensee did not ensure staffing ratios were met, the licensee did not follow the plan of operation, and facility staff are not administering medications as prescribed revealed the following: During the course of the investigation, LPA inspected the facility, interviewed PM, and obtained and reviewed copies of the client roster, staff roster, Client #1’s (C1) manual restraint debriefing logs, C1’s needs and services plan, Client #2’s (C2) needs and services plan, the facility’s staff schedule, Staff #1’s (S1) training records, C1’s Medication Administration Record (MAR), and C2’s MAR.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
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 5
Control Number 22-AS-20251015092302
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: 10/23/2025
NARRATIVE
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Regarding the allegation that facility staff did not properly document manual restraint debriefings: it was alleged that the manual restraint debriefing logs from April 2025 through September 2025 did not consistently document consumer involvement or the date and time that the debriefing occurred. PM admitted the allegation, stating that for C1’s manual restraint debriefing logs for April 19, 2025, C1 was hospitalized and could not participate in the manual restraint debriefing but this was not documented on the manual restraint debriefing logs, although PM did speak to C1 every day while C1 was in the hospital and completed the debriefing which was not documented. LPA reviewed C1’s manual restraint debriefing logs from April 2025 through September 2025 and noted the four manual restraint debriefing logs for April 19, 2025, do not document the date and time of the debriefing or C1’s refusal or inability to participate. The information obtained corroborated the allegation.

Regarding the allegation that the licensee did not ensure staffing ratios were met: it was alleged that the September 2025 schedule did not meet the staffing ratios for C1 and C2. PM admitted the allegation, stating that there were instances when the facility did not meet staffing ratios, and there were other times when managers were covering shifts, but the managers covering shifts was not documented on the schedule. LPA reviewed C1’s needs and services plan which states they require two staff assigned to them 24 hours a day and C2’s needs and services plan which states they require one staff assigned to them 24 hours a day. LPA reviewed the facility’s staff schedule for September 2025 which shows that the facility did not meet the staffing ratios for certain shifts on multiple days in September as documented on the bottom three columns of the schedule. The information obtained corroborated the allegation.

Regarding the allegation that the licensee did not follow the plan of operation: it was alleged that S1 did not have documentation of 25 hours of continuing education from May 2024 through May 2025 as required by the facility’s plan of operation and instead had only 22.75 hours of documented continuing education. LPA reviewed the facility’s plan of operation, which states that direct care staff shall complete a minimum of 20 hours of continuing education annually as well as five hours per year of training in person-centered planning, positive behavior supports, trauma-informed care, and cultural competency. LPA reviewed S1’s training records which show they received 20.96 hours of continuing education from May 2024 through May 2025. The information obtained corroborated the allegation.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20251015092302
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: 10/23/2025
NARRATIVE
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Regarding the allegation that facility staff are not administering medications as prescribed: it was alleged that C1’s MAR does not show that C1 received their complete course of Doxycycline, C1 had no bowel movements on multiple days between April 2025 and September 2025 and Bisacodyl and mineral oil were not administered as ordered, C2’s MAR does not show that C2 received their complete course of Amoxicillin, and C2 had multiple days of no bowel movements between April and September 2025 but their Bisacodyl was not administered as ordered. PM denied that C1’s Doxycycline was not administered as prescribed, stating C1 was hospitalized during the course, completed their course at the hospital, and returned to the facility after the course was already over. C1’s MAR shows that C1 was to take Doxycycline starting April 16, 2025 for 10 days, that C1 took the Doxycycline from April 16, 2025 until they were hospitalized on April 19, 2025, and that they did not return to the facility until May 1, 2025, which is after the 10-day course ended on April 26, 2025, which corroborated PM’s statements. Review of C1’s MAR shows an order for Bisacodyl which states it should administered as needed if there is no bowel movement for one day and noted that it should have been given, but was not, on May 13, 2025 and August 22, 2025, because C1 had not had a bowel movement for almost two days. PM denied that C2’s Amoxicillin was not administered as prescribed, stating C2 was prescribed one order for Amoxicillin and then another, stronger, dose a few days later, with the weaker dose being discontinued by C2’s doctor. C2’s MAR shows that C2’s Amoxicillin was changed to a new dosage, with the old dosage discontinued, and the new dosage given until it was completed, which corroborated PM’s statements. PM denied that C2 was not given their Bisacodyl as prescribed, stating the doctor’s order does not specify a schedule for administration and simply states that it is as needed. LPA reviewed C2’s MAR which corroborates PM’s statement that the doctor’s order does not specify a schedule. The information obtained corroborated the allegation.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. 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: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20251015092302
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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2025
Section Cited
CCR
85168.3(c)
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85168…. (c) Documentation of the debriefing meeting in the client's record shall include … any refusal by the client to participate in the review. This requirement was not met as evidenced by:
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Licensee stated they will update their manual restraint debriefing logs to include instructions regarding clients’ refusal or inability to participate and submit proof to LPA by POC due date.
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Based on documents and admission, the licensee did not properly document C1’s participation, refusal, or inability to participate in their April 19, 2025, debriefing logs, which poses a potential personal rights risk to persons in care.
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Type B
11/20/2025
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision (a) … (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee stated they will submit a plan to ensure the facility meets the clients’ staff ratios to LPA by POC due date.
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Based on documents and admission, the licensee did not meet the staffing ratio in both clients’ needs and services plans for multiple days in September 2025, which poses a potential 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20251015092302
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: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2025
Section Cited
CCR
80022(k)
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80022 Plan of Operation (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. This requirement was not met as evidenced by:
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Licensee stated they have already had S1 properly trained for continuing education for the next year and LPA confirmed during the inspection. POC CLEARED.
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Based on documents, the licensee did not ensure S1 received 25 hours of continuing education annually as required by the facility’s plan of operation, which poses a potential safety risk to persons in care.
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Type B
11/20/2025
Section Cited
CCR
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee stated they will conduct medication training and submit proof to LPA by POC due date.
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Based on documents and admission, the licensee did not ensure C1 received assistance with medications when C1 was not given their Bisacodyl as ordered, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.
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This is an amended report
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: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5