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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601027
Report Date: 01/19/2024
Date Signed: 01/19/2024 01:17:40 PM


Document Has Been Signed on 01/19/2024 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 ASC, 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: 68DATE:
01/19/2024
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ruth Tistoj - AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 1/19/2024 Licensing Program Analysts- LPA’s Socorro Leandro and Alfonso Iniguez conducted an announced schedule pre-licensed visit. LPA’s Leandro and Iniguez met with Ruth Tistoj /Administrator. LPA’s explained the purpose of this visit.

During this visit LPA’s conducted a review of (5) residents Medication and Administration Records (MAR) and observed that there were discrepancies in the documentation of the resident’s medications.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. (See D page for details)

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Ruth Tistoj/Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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 01/19/2024 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 191601027

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2024
Section Cited
CCR
87465(a)(6)

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87465 Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
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Licensee will conduct in-service on the importance of medication documentation and a will send LPA a copy of in-service signed and dated by staff in attendance by POC due date.
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Based on observation and record review, the licensee did not comply with the section cited above as medications were not checked off on MAR and there was no documentation detailing if resident took or refused the prescribed medications which poses/posed a potential health, safety or personal rights 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.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2