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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601027
Report Date: 12/13/2023
Date Signed: 12/13/2023 01:17:10 PM


Document Has Been Signed on 12/13/2023 01:17 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: 69DATE:
12/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Ruth Tistoj / AdministratorTIME COMPLETED:
01:16 PM
NARRATIVE
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On 12/13/2023, Licensing Program Analyst- LPA Alfonso Iniguez conducted a Case Management- Deficiencies at the facility named above. LPA met with Ruth Tistoj /Administrator. LPA explained the purpose of today’s visit.

During the 10-day complaint investigation on 12/13/23, LPA found that (R#1) elopement from the facility on 12/3/23 was not reported to CCLD. In addition, during the physical tour of the facility, LPA observed the back gate that leads to the street was not closing properly.

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 to Administrator- Ruth Tistoj.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2023 01:17 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: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2023
Section Cited
CCR
87211(a)(D)

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87211 Reporting Requirements - (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement was not met as evidenced by:
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The licensee will adhere to Title 22 Section 87211. Plan of correction is for Licensee to submit a LIC 624 Incident Report POC due: 12/15/23 of the incident associated with (R#1)’s incident.
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Based on observation and records review, the licensee failed to report (R#1)’s elopement from the facility to CCLD. This citation poses a potential health and safety risk to residents in care.
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Type B
12/15/2023
Section Cited
CCR87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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Lincensee will ensure all back gates are working properly. In addition, licensee will submitt proof of repairs to LPA via email before POC due date.
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Based on observation the licensee failed to keep the back gate working properly, this contributed to (R#1) leaving the facility on the night of 12/3/23. This citation poses a potential health and safety risk to 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: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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