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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191601027
Report Date: 12/13/2023
Date Signed: 12/13/2023 01:16:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/05/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20231205143021
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
UNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Ruth Tistoj / AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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 Facility failed to provide supervision, resulting in a resident wandering from the facility.
INVESTIGATION FINDINGS:
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On 12/13/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Ruth Tistoj /Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Reporting Party (RP), Resident Interview (R#1) and Staff Interviews(S#1-S#5). LPA obtained and reviewed the following documents: Employee Telephone Number List, November, and December 2023 Staff Schedule, copy of (R#1) Physician’s Report for Residential Care Facilities for the Elderly (RCFE) LIC 602A and facility Incident Report dated on 12/3/23 at 8:40 PM and Physical tour of the facility.

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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 11-AS-20231205143021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/13/2023
NARRATIVE
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Investigation Revealed the Following:

Allegation: Facility failed to provide supervision, resulting in a resident wandering from the facility.

The details of the complaint alleged that the facility failed to supervision resulting in a resident wandering from the facility.



During the records review, LPA Iniguez reviewed (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) LIC 602A; it is marked that (R#1) is not able to leave the facility unassisted. In addition, LPA reviewed the facility’s incident report; it is written that on 12/3/23 at 8:40 PM (R#1) escaped from the sliding door in their room and went through the dining room sliding door to get to the back gate. The incident report states that (R#1)’s physician and family were informed by the facility staff about the incident the same night.

During the physical tour, LPA and Administrator checked the back gate where (R#1) went out into the street; LPA noticed the gate’s magnet latch was not working correctly; therefore, (R#1) was able to open the door easily the night of 12/3/23.

During an Interview with the administrator (A#1), she stated that she just got hired on 12/12/23 and she just found out today about (R#1)’s elopement from the facility on 12/3/23. LPA asked her if they reported that incident to CCLD, and she said she didn’t know.

During interviews with staff (S#2-S#5), 4 out of 4 confirmed that (R#1) wandered out of the facility into the street on 12/3/23 at approximately 8:00 PM. In addition, 4 out of 4 staff stated that (R#1) was returned by the police the same night, between 8:45 PM and 9:00 PM, without harm. Based on the facility incident report, (R#1)’s family and physician were informed about this event the same night. In addition, LPA asked (S#2, S#3, S#4, and S#5) if they were fully staffed that night; they answered yes, they had (6) caregivers, (1) LVN, and (1) janitor. Furthermore, (S#5) and (S#4) stated that between 7:00 PM and 8:00 PM, they were doing rounds and outing residents to sleep and that when they discovered (R#1) was not in their room.

LPA tried to interview (R#1), but they could not answer LPA’s questions due to their medical condition.

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: 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20231205143021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/13/2023
NARRATIVE
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During this investigation, LPA 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.

An exit interview was conducted, and a copy of the Complaint Report was given to Ruth Tistoj/Administrator.

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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20231205143021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
12/14/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following.. (2) To be accorded safe, healthful and comfortable accommodations...
This requirement was not met as evidenced by:
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The administrator will ensure the safety of all residents. In addition, administrator will submit to CCLD by 12/14/23 a plan where the facility will ensure the safety of all residents. The administrator agreed that all staff will be advised to be on "high alert" meaning being more vigilant in monitoring exits while a Plan of Correction is being developed. POC due date: 12/14/23.
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Based on interviews and records review. Licensee did not ensure the safety of (R#1) who wandered out of the facility, went missing, unsupervised by staff. (R#1) needs assistance when leaving the facility according to physician's report 6/27/23.This violation poses an immediate health and safety risk to clients 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4