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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191601027
Report Date: 10/17/2024
Date Signed: 10/17/2024 10:18:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2024 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240111115409
FACILITY NAME:BRITTANY HOUSEFACILITY NUMBER:
191601027
ADMINISTRATOR:COLLEN ROZATIFACILITY TYPE:
740
ADDRESS:5401 E. CENTRALIA STREETTELEPHONE:
(562) 421-4717
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:0CENSUS: 66DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Mandy Taylor-Executive DirectorTIME COMPLETED:
10:17 AM
ALLEGATION(S):
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Resident sustained multiple unexplained injuries while in care.
INVESTIGATION FINDINGS:
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On 10/17/2024 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Mandy Taylot/Executive Director. LPA explained the purpose of this visit.

Investigation Consisted of: CCLD staff referral accepted dated 1/12/24 and completed investigation on 5/28/24, CCLD staff interview with Witness 1 (W#1) dated 1/18/24, CCLD staff interview with Witness 2 (W#2) dated 1/30/24, CCLD staff interview with former Facility Administrator (A#1) dated 2/13/24, CCLD staff interview with Resident 1 (R#1) dated 2/13/2024, CCLD staff interview with Resident 2 (R#2) dated 2/13/24, CCLD staff interview with Facility Staff 1 (S#1) dated 2/13/24, CCLD staff interview with Facility Staff 2 (S#2) dated 2/13/24, CCLD staff interview with Facility Staff 3 (S#3) dated 2/13/24, CCLD staff interview with Witness 3 (W#3) dated 5/21/24, CCLD staff review of EMS Incident Report dated 1/3/24 and CCLD staff review of Long Beach Memorial Hospital Records dated 1/3/24.

Evaluation Report continues LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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 11-AS-20240111115409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 191601027
VISIT DATE: 10/17/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Resident sustained multiple unexplained injuries while in care.

The details of the complaint alleged that (R#1) sustained unexplained injuries while in care.



During the records review, the department reviewed the following: CCLD staff Investigation dated 5/28/24, CCLD staff review of EMS Incident Report dated 1/3/24, and CCLD staff review of Long Beach Memorial Hospital Records dated 1/3/24. The Emergency Medical Service (EMS) report stated that on January 3, 2024, at approximately 0517 hours, the Unit was dispatched to 5401 E. Centralia St., Long Beach, CA. 90808. At approximately 05:28 hours, EMS arrived on the scene. The blood looked dark so that the patient may have been down on the ground for a while. Dried blood was also noticed in the mouth. The patient was transported to Long Beach Memorial, the closest trauma center. In addition, the department reviewed The Long Beach Memorial Medical Records, and there it is stated that (R#1) was admitted on 01/03/2024 regarding facial trauma. (R#1) was found down on the floor of their room at the assisted living.

On 1/18/24, during an Interview conducted by CCLD staff with Witness 1 (W#1), (W#1) stated that they received a referral from the bedside nurses, who had concerns about (R#1) because they were observed to have several unexplained injuries. (R#1) had bruises, scratches, scattered scabs, a left nasal bone fracture, and a bruised lip. Additionally, EMS noted that (R#1) was found on the floor with dark and dried blood around their right eyebrow and mouth.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20240111115409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 191601027
VISIT DATE: 10/17/2024
NARRATIVE
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On 2/13/24, during an Interview conducted by CCLD staff with former Facility Administrator (A#1), (A#1) admitted to occasionally being understaffed and confirmed that on the day of the incident, there was only one caregiver (S#1) working the NOC shift in the memory care unit with approximately 18 residents including (R#1). When (A#1) conducted interviews with (S#1), they stated they were busy tending to another resident and had failed to conduct supervision checks. At approximately 05:30 hours, when (R#1) was due for their vital checks, facility staff found them on the floor facing down with a cut above their right eye.

On 2/13/24, during an Interview conducted by CCLD staff with Facility Staff (S#1), (S#1) admitted to not conducting appropriate supervision rounds checks due to tending to another facility resident. The last time (S#1) checked on (R#1) was at approximately 02:30 hours. (S#1) admitted to not conducting a thorough check; the check was done from an outside view through a slightly open door of (R#1)’s room.

On 1/30/24, during an Interview conducted by CCLD staff with Witness 2 (W#2), (W#2) stated that previously they had received photographs via text message regarding (R#1)’s podiatrist informing them that (R#1)’s toenails have been observed to be long and unkempt. (W#2) stated that they were unaware of (R#1)’s incident at the facility.

On 2/13/24, during an Interview conducted by CCLD staff with Resident 1 and 2 (R#1 and R#2), (2) out of (2) residents were not able to answer Investigator Garcia’s questions due to cognitive impairment.

On 5/21/24, during an Interview conducted by CCLD staff with Witness 3 (W#3), (W#3) denied ever witnessing any type of neglect/ or abuse by facility staff members.

On 2/13/24, during an Interview conducted by CCLD staff with Facility Staff (S#2 and S#3), (2) out of (2) facility staff denied allegation of neglect/lack of care.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20240111115409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 191601027
VISIT DATE: 10/17/2024
NARRATIVE
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During this investigation, the department found sufficient evidence to support the above-mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

-Immediate Civil Penalty rendered.

An exit interview was conducted, and a copy of the Complaint Report was given to Mandy Taylor/Executive Director.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20240111115409
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 191601027
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2024
Section Cited
CCR
87466
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87466 Observation of the Resident.
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

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Licensee will ensure the observation of residents at all times. As plan of correction, administrator will send a written plan to address when is a shortage of staff. Written plan will be sent to LPA by due date via email.
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Based on a review of records and interviews, the facility staff failed to ensure (R#1) was not check properly causing them to fall and being left on the floor for an extended period of time.

This poses an immediate health and safety risk to all residents 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5