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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601027
Report Date: 11/20/2023
Date Signed: 11/20/2023 03:41:11 PM


Document Has Been Signed on 11/20/2023 03:41 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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:170CENSUS: 70DATE:
11/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:54 PM
MET WITH:Mike Burtein/ConsultantTIME COMPLETED:
02:55 PM
NARRATIVE
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On 11/20/23, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management – Deficiencies to the facility name above. LPA meet with Mike Burstein/Consultant.

On 11/20/2023 during a 10-day complaint visit LPA found out that consultants are not associated at this facility.


Civil Penalty Assessed.

Deficiencies cited under California Code of Regulation Tittle 22, Division 6 Chapter 8 are being cited on the attached LIC 809D.


Exit interview conduct, appeal rights discussed and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/20/2023 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 191601027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement was not met as evidence by:
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Licensee will ensure all staff is associated at the facility. In addition, licensee must submitt proper documentation to CCL to associate consultants, proof of correction must be sent to LPA via email before POC due date.
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Based on a review of records and interviews, licensee did not associate the two consultants overseen the administration of the facility. 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: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2