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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601667
Report Date: 09/12/2024
Date Signed: 09/12/2024 06:16:00 PM

Document Has Been Signed on 09/12/2024 06:16 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:C. C'S RESIDENTIAL FACILITY FOR ADULTSFACILITY NUMBER:
191601667
ADMINISTRATOR/
DIRECTOR:		BEVERLY BRINSONFACILITY TYPE:
735
ADDRESS:11101 DOTY AVENUETELEPHONE:
(310) 560-7975
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 6DATE:
09/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Beverly BrinsonTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management Visit on Thursday, September 12, 2023. 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 that the purpose of today's visit was to amend the Complaint Report received by Community Care Licensing on September 05, 2023, under Complaint Control Number 11-AS-20230905171928. The amended LIC9099 dated September 12, 2024, will supersede the original LIC9099 dated August 22, 2024, to reflect the correct allegation.

A copy of the Facility Evaluation Report LIC809 was provided to Licensee Beverly Brinson.

There were no deficiencies cited.

An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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