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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601667
Report Date: 06/26/2025
Date Signed: 06/27/2025 10:44:37 AM

Document Has Been Signed on 06/27/2025 10:44 AM - 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:
06/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Beverly Brinson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 6/26/25, Licensing Program Analyst (LPA) Felisa Shirley arrived unannounced to conduct an Annual Required - 1 Year Inspection and met with Administrator, Beverly Brinson. LPA disclosed the purpose of the inspection was granted entry into facility by the Licensee. The current census is 6.

Walk through inspection was conducted by LPA Shirley and Beverly inside and outside to ensure that there are no health and safety hazards.

DINING ROOM: LPA Shirley and Beverly inspected the dining room and found it to be clean and all the furniture was in good working order. There were adequate number of chairs and a place at the table for all clients in the facility.

KITCHEN: LPA Shirley observed the kitchen to be clean and sanitary and all appliances were operable. The facility has a sufficient supply of perishable and non-perishable foods. The pantry was well stocked. Knives were properly secured in a cabinet in the Administrator’s office. LPA Shirley noted that the water temperature delivered at 119.9 F.

LIVINGROOM: LPA Shirley and Beverly inspected the Livingroom. LPA Shirley observed it to be clean and free of dirt. There were working lights, a working landline phone, and no fireplace or open face heating.

Con'd on 809-C
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/26/2025
NARRATIVE
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BEDROOMS: LPA Shirley and Beverly inspected the bedrooms. There are 3 bedrooms with 2 clients per room with beds, accommodating chairs and dressers for every client.

BATHROOM: LPA Shirley and Beverly toured both bathrooms. LPA Shirley found the bathrooms to be clean, paper towels and soap. There was functioning toilet with handrails and shower.



LAUNDRY ROOM: LPA Shirley and Beverly inspected the backyard and observed an enclosed locked laundry room with washer and dryer which were in working order.

BACKYARD: LPA Shirley and Beverly inspected the side of the house yard and backyard and found them to be clean and a shaded area for the residents. LPA observed that there was no pool or bodies of water.

LPA Shirley found there to be several hardwired smoke/carbon monoxide detectors located throughout the facility. LPA found that the hallway was clear of any obstructions. Fully stocked linen closets in the hallway.

LPA Shirley found there to be 4 fully charged fire extinguisher. They were maintained and serviced yearly. Last inspection was April 2025. Inspection record was up to date and tags visible.

LPA Shirley checked client’s medications. All medications were secured in a locked cabinet located inside the Administrator’s office. LPA Shirley checked the client’s MAR with labeled medications. LPA found there to be a fully stocked first aid kit with an up-to-date Red Cross manual.

LPA Shirley reviewed all client files and found that they contained all required documents. LPA reviewed all Staff Personal files, and LIC 500 and found that all staff are associated with our records in Guardian.

During file review, LPA Shirley observed that there was 1 client that did not have their TB test results. LPA Shirley also observed that there were 2 staff that did not have their TB test results. LPA reviewed the staff files and observed that there were 2 staff that did not have their First Aid training certification.

Con'd on 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/26/2025
NARRATIVE
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Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, Divisions 6 chapter 1, see LIC 809D.

Deficiencies were cited during today's visit.



An exit interview was conducted, and plans of corrections were developed, with Beverly Brinson. A copy of this report and appeals rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2025 10:44 AM - It Cannot Be Edited


Created By: Felisa Shirley On 06/26/2025 at 03:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the Administrator did not comply with the section cited above in which all four staff members did not have their TB test results which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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Administrator shall submit copies of TB test results. Test results must be submitted by due date: 7/10/25 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in which 2 staff members, Grissella Stafford and Guillermo Hernandez did not have their First Aid Training Certifications on file which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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Administrator shall submit copies of First Aid Certifications. Certifications must be submitted by due date: 7/10/25 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Felisa Shirley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2025 10:44 AM - It Cannot Be Edited


Created By: Felisa Shirley On 06/26/2025 at 03:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, client, Donta Veasey did not have record of TB test results on file which poses a potential health, safety risk to persons in care.
POC Due Date: 07/10/2025
Plan of Correction
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Administrator shall submit copies of the clients TB test results. Certifications must be submitted by due date: 7/10/25 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Felisa Shirley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2025


LIC809 (FAS) - (06/04)
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