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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191601667
Report Date: 03/12/2025
Date Signed: 03/21/2025 01:59:20 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
12/13/2024 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241213122142
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:
03/12/2025
UNANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Beverly Brinson - AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff unlawfully evicted a client.
INVESTIGATION FINDINGS:
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"Please note that this amended Complaint Investigation Report LIC9099 dated 3/20/2024 will supersede the original LIC9099 dated 3/12/2024 to clarify findings.

On 03/12/2025, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent visit to deliver findings for the allegation listed above. LPA met with Beverly Brinson and explained the purpose of the visit. LPA was granted entry to the facility

The investigation consisted of the following:

On 12/13/2024 the following documents were reviewed/obtained: Personnel report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Medication Logs, Appraisal & Needs Service Plan, Functional Capability Assessment, Preplacement Appraisal Information, Consent Forms, College Medical Center Admission and Discharged Records. Interviews were conducted with administrator and Witness 1 (W1) and Witness 2 (W2). Resident 1 (R1) was not at the facility and was unavailable for an interview.

CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Benita Yates
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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 3
Control Number 11-AS-20241213122142
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: 03/12/2025
NARRATIVE
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Investigation revealed the following:

Allegation: Staff unlawfully evicted a resident
On 12/13/2024 LPA Bunker reviewed facility records and found no eviction letter on file for resident 1 (R1).

On 12/13/2024 LPA Bunker conducted an interview with Licensee/Administrator Beverly Brinson who stated that the facility did not unlawfully evict the resident. Administrator stated she answered all calls and did not refuse to allow the resident to return. S1 stated that the resident is scheduled to return to the facility on Saturday morning, December 14, 2024, at 10:00 A.M. S1 denied the allegation. On 12/13/2024 LPA Bunker spoke to Witness 1 (W1), who stated resident was admitted to College Medical Center on 12/03/2024 and as of 12/11/2024 was ready to be discharged to his boarding care facility. W1 stated facility

Licensee/Administrator refused to allow resident back into the facility and would not find an alternative placement and no longer answered the phone when follow-up calls were made. On 12/13/2024 the department spoke to witness 2 (W2), who confirmed R1 was ready to return to facility as of 12/11/2024 and facility staff refused to allow him back.

Based on the department 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-Cs, and LIC9099-D were provided to STAFF

An exit interview was conducted.


CONTINUED ON LIC9099-C
SUPERVISORS NAME: Benita Yates
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20241213122142
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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/28/2025
Section Cited
CCR
85068.5(a)(4)(c-e)
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The licensee shall be permitted to evict a client by serving with a 30-day notice...(c)The licensee shall set forth in the notice to quit the reasons for the eviction...(d)The licensee shall notify or mail a copy of the notice to the client's representative...(e) A written report of any eviction
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POC: The Licensee will review regulations 80068.5 and 85068.5 Eviction Procedures and submit a written plan on how 30-day or 3-day evictions will be handled according to the Title 22 Regulation requirements. Licensee will submit a POC to CCLD via fax or email by POC due date.
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processed in accordance...sent to the licensing agency within 5 days of the eviction.This requirement is not met as evidenced by:Licensee refused to take R1 back and not serve an eviction notice.This violation poses a potential personal rights risks for clients.
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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: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3