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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191601667
Report Date: 08/22/2024
Date Signed: 09/12/2024 05:46:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
09/05/2023 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20230905171928
FACILITY NAME:C. C'S RESIDENTIAL FACILITY FOR ADULTSFACILITY NUMBER:
191601667
ADMINISTRATOR:BEVERLY BRINSONFACILITY TYPE:
735
ADDRESS:11101 DOTY AVENUETELEPHONE:
(310) 560-7975
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY:6CENSUS: 6DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Beverly BrinsonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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 Facility staff did not prevent a resident from physically assaulting another resident with a weapon.
INVESTIGATION FINDINGS:
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"Please note that this amended Complaint Investigation Report LIC9099 dated 09/12/2024 will supersede the original LIC9099 dated 08/22/2024, to include the correct allegation."
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Thursday, August 22, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Licensee Beverly Brinson. LPA Bunker explained the purpose of today's visit. "This amended LIC9099 dated 09/12/2024 supersedes the original LIC9099 dated 08/22/2024, to include the correct allegation."
The investigation consisted of the following: LPA Bunker conducted interviews with staff members 1-2 (S1-S2), as well as residents 1 (R1) and R3 through R6 (R3-R6). R2 was unavailable for an interview. LPA Bunker asked questions relevant to the nature of the complaint. Licensee Mrs. Brinson and LPA Bunker toured the entire facility buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No evidence of neglect or abuse was observed during today's visit. LPA Bunker requested and reviewed the records of R1 and R2. See continued LIC9099-C page 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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 3
Control Number 11-AS-20230905171928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: C. C'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 191601667
VISIT DATE: 08/22/2024
NARRATIVE
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Continued LIC9099-C page 2. LPA Bunker requested copies of the physician's report, medical records, admission agreement, identification and emergency information, medication log, Medication Administration Records (MARs), medical assessment, consent forms, the release of resident medical information, unusual incident reports, appraisal/needs and services plan, UCLA Harbor Medical admission and discharge records, and medical records, Norwalk State Hospital records, and Inglewood Police Department (IPD) police report.
Allegation: Neglect/Lack of Care and Supervision. S1-S2 interviewed stated that R1 was physically assaulted by R2 while sleeping in his bed. R1 sustained two stab wounds, one to the chest and another to his right pinky finger. After running across the street for help, R1 was stabbed again by R2 under his upper left armpit. Residents R3 through R6 interviewed stated they did not witness the stabbing incident. S1-S2 stated that R1 was later medically cleared from the hospital and discharged back to the facility. S1, Licensee Mrs. Brinson, stated that R2 was arrested and did not receive an eviction notice from the facility. Both R1 and R1's Public Guardian agreed with the decision to return R1 to the facility and were fully informed of the incident. Investigation revealed the following: Staff members S1 and S2, as well as residents R1 and R3 through R6, were interviewed. S1 and S2 stated that R1 was physically assaulted by R2 while R1 was sleeping, sustaining injuries to his chest and right pinky finger. According to findings from the Investigation Branch (IB), Investigator Dennis Seng noted that surveillance footage captured R2 stabbing R1 in the armpit and then running across the street for help. It was determined that the facility staff failed to provide adequate care and supervision to the residents.S1 and S2 stated they immediately contacted 911, the paramedics, and the Inglewood Police Department, who all arrived at the facility. R1 was treated by paramedics on the curb before being transported to Harbor UCLA Medical Center on August 31, 2023, for further evaluation. R1 was discharged on September 1, 2023, after being medically cleared and returned to the facility and S2 reported that R2 was arrested by Inglewood police officers. S1-S2 stated that R2 did not receive an eviction notice while in care and was not evicted from the facility. S1-S2 stated the unusual incident was reported to Community Care Licensing and the appropriate agencies in a timely manner. S1-S2 emphasized that their staff is a dedicated, trained, and competent team, committed to providing the necessary care and supervision to ensure the safety of all residents. Residents R3 through R6 stated they did not witness the stabbing incident but were aware of it. S1-S2 agreed that the stabbing incident did occur. Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 1 are being cited on the attached LIC9099-D. Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC9099-D Confidential Names LIC 811 were provided to Licensee Beverly Brinson. An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230905171928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: C. C'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 191601667
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2024
Section Cited
CCR
80072(a)(3)
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80072 (a) (3) Personal Rights

To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.
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The licensee needs to submit a written plan addressing residents' personal rights, ensuring that residents are protected from corporal or unusual punishment.
This plan must be submitted by the POC due dated 09/09/2024
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The facility staff did not prevent a resident from being physically assaulting another resident with a weapon. The violation poses a potential health and safety risk to residents in care.
The violation poses a potential health and safety risk to residents in care.
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Type B
09/09/2024
Section Cited
CCR
80078(a)
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80078 (a) Responsibility for Providing Care and Supervision
The licensee shall provide care and supervision as necessary to meet the client's needs. The facility staff failed to prevent a resident from physically assaulting another resident with a weapon while in care.
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The licensee needs to submit a written plan detailing staff responsibilities for providing care and supervision to meet residents' needs. This plan must be submitted by the POC due of dated 09/09/2024.
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The violation 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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3