191601667-2-28-2025-11-AS-SCIS-DEQ2VE-20250312174349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191601667
Report Date: 02/28/2025
Date Signed: 02/28/2025 04:21:39 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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 Elvira Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230905171928

FACILITY NAME:	C. C'S RESIDENTIAL FACILITY FOR ADULTS		FACILITY NUMBER:	191601667
ADMINISTRATOR:	BEVERLY BRINSON		FACILITY TYPE:	735
ADDRESS:	11101 DOTY AVENUE		TELEPHONE:	(310) 560-7975
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90303
CAPACITY:	6	CENSUS: 6	DATE:	02/28/2025
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Beverly Brinson		TIME COMPLETED:	04:45 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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This report supersedes the report dated 1/9/2025 and was created to clarify information and citations issued.

On 02/28/25 the department conducted an unannounced complaint visit to the facility listed above. The department met with staff member BLANK and explained the purpose of today's visit was to redeliver findings and were granted entry to facility grounds.

The investigation consisted of the following: The department conducted interviews with Staff 1 – Staff 2 (S1-S2), Resident 1 (R1) and Resident 3 to Resident 6 (R3-R6). Several attempts were made to interview Resident 2 (R2), but they refused to be interviewed.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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-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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: C. C'S RESIDENTIAL FACILITY FOR ADULTS	FACILITY NUMBER: 191601667
	VISIT DATE: 02/28/2025

NARRATIVE

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On 9/06/2023 LPA Pamela Bunker and Staff Jerry Brinson(staff 2 -S2) toured 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 the visit. The department requested and reviewed the following records for R1 and R2: physician's report (R1 only), admission agreement, identification and emergency information, Medication Administration Records (MARs), unusual incident reports, appraisal/needs and services plan, UCLA Harbor Medical records for R1 and Inglewood Police Department (IPD) police report. An employee schedule was requested for the month of 8/2023 and as of the date of this report was not received.

Investigation revealed the following:

Allegation: Facility staff did not prevent a resident from physically assaulting another resident with a weapon. It is being alleged that a facility resident was able to stab another resident due to a lack of supervision by facility staff.

On 11/29/2023 the department arrived at the facility to conduct interviews and observed that door was opened by resident 3 (R3), who then led them across the street to house of Administrator Beverly Brinson. The department reviewed facility files for R1 and per medical records from Harbor UCLA Hospital, R1 was admitted to Harbor UCLA Hospital on 8/31/2023 with two stab wounds, a 2.5cm linear laceration over the little finger of his right hand and a 7cm linear laceration over their left upper chest. Per police report from the Inglewood Police department, on 8/31/2023 two officers responded to a call at facility address. Per police report, at approximately 10:30pm R1 was awoken by R2, who stabbed at him, which R1 blocked with his hand. R1 ran out of the house and yelled for help with R2 chasing after him. R1 was running to house of S1 (Administrator Beverly Brinson), which is around the corner, but R2 was able to catch up to R1 in the driveway of S1’s house and stab him in the abdominal area before running away. 911 was called by Administrator Brinson and R1 received treatment from paramedics before being sent to the hospital and R2 was arrested.

On 11/29/2023 the department interviewed facility Administrator Beverly Brinson (S1). During interview S1 stated both her and S2 reside in houses across the street from the facility.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC9099 (FAS) - (06/04)

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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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: C. C'S RESIDENTIAL FACILITY FOR ADULTS	FACILITY NUMBER: 191601667
	VISIT DATE: 02/28/2025

NARRATIVE

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S1 stated that on 8/31/2023, both S1 and S2 were working, and S1 was in her house across the street when R1 ran to S1’s house and stated that R2 was trying to kill them. Per S1, R1 was bleeding from hand and left side, S1 called 911 and paramedics came, treated R1 and took him to Harbor UCLA Hospital. During interview, S1 stated that she noted a change in behavior in R2 in June or July of 2023 and that they stopped attending day program around the same time. S1 also stated she did not have a Physicians Report or treatment plan for R2, just his medication list.

On 11/29/2023 the department interviewed Staff 2 (S2). S2 stated during interview that on 8/31/2023 he was sleeping at his own home, across the street from the facility. S2 saw R1 run to S1’s home and as he ran around a car in the driveway, R2 stabbed him. S2 also stated during interview that they noted in June of 2023 that there were changes in R2’s behaviors and that they escalated to physical in July of 2023. S2 reported actions to S1, facility administrator but was unaware of what action, if any, were taken.

On 11/29/2023 the department interviewed residents Resident 1 (R1) and Resident 3 to Resident 6 (R3-R6). Of those interviewed, R5 was unable to answer questions due to diagnosis. Out of those interviewed and able to answer, 1 out of 4 confirmed the allegation while 3 out of 4 stated they did not see it happen. During interviews, the department asked residents if staff checked on them often, of those interviewed that could answer questions, 3 out of 5 stated staff lived across the street and rarely checked on residents, with two residents stated they had to go across the street if they needed anything. Based on LPAs observations, interviews and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (1) are being cited on the attached LIC 9099D.

An immediate $500 Civil Penalty assessed, please see LIC421IM.

An exit interview was conducted, appeal rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-Cs, LIC9099-D and LIC421IM were provided to Licensee, Beverly Brinson.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: C. C'S RESIDENTIAL FACILITY FOR ADULTS	FACILITY NUMBER: 191601667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 03/01/2025 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078(a) Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	The licensee agreed 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 03/01/2025.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, on 10/31/2023, R2 stabbed client R1. The violation poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC9099 (FAS) - (06/04)

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