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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601667
Report Date: 01/31/2025
Date Signed: 01/31/2025 02:28:33 PM

Document Has Been Signed on 01/31/2025 02:28 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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:
01/31/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Beverly BrinsonTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 1/31/2025 Licensing Program Analyst (LPA) Troy Watson conducted an unannounced Case Management - Deficiencies visit. LPA Watson was greeted by Beverly Brinson , purpose of the visit was discussed and LPA was granted access to the facility.

The purpose of this visit is to assess a civil penalty in regards to a complaint with complaint control number 11-AS-20230905171928. An immediate civil penalty of $500 is being assessed for violation of Section 80078(a). During the visit, the licensee was informed that an additional civil penalty determination is pending.
An exit interview was conducted, and copies of this case management, amended D page and Civil Penalty were provided to the licensee.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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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