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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198200202
Report Date: 06/18/2024
Date Signed: 06/19/2024 09:54:13 AM

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
06/13/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20240613131143
FACILITY NAME:JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTSFACILITY NUMBER:
198200202
ADMINISTRATOR:BEVERLY BRINSONFACILITY TYPE:
735
ADDRESS:14004 DAPHNETELEPHONE:
(310) 560-7975
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY:6CENSUS: 3DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Beverly Brinson, LicenseeTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that hazardous items were inaccesible to residents
Staff mismanaged resident's medication
Staff mismanaged resident's P & I funds
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*On 6/19/24 LPA Felisa Shirley returned to this facility to finalize investigation.

On 6/17/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced complaint visit to the address listed above. LPA and LPM arrived and spoke to staff, Jerry Brinson and the purpose of the visit was discussed. The Licensee, Beverly Brinson arrived shortly after. LPA was granted access to the facility.

The investigation consisted of the following: On 6/17/24 LPA reviewed: Staff files, resident files, P&I records, the MAR of one resident, toured the facility and interviewed both staff.




The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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 8
Control Number 11-AS-20240613131143
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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202
VISIT DATE: 06/18/2024
NARRATIVE
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Allegation: Staff did not ensure the hazardous items were inaccessible to residents

On 6/17/24, LPA observed powered detergent in the laundry area and a can of Lysol accessible to residents in care. On 6/17/24, interviewed staff-1 and staff-2 (S-1 & S-2). LPA ask, does staff ensure that hazardous items are inaccessible to residents. Of those interviewed, 2 out of 2 answered yes. LPA interviewed resident 1 (R-1). Residents R-2 and R-3 were not available for interview. LPA ask, does staff ensure that hazardous items are inaccessible to residents, and R-1 answered, locked up. Based on observations, the department did find sufficient evidence to support allegation. The preponderance of evidence has been met therefore the allegation is Substantiated.

Allegation: Staff mismanaged resident’s medication

On 6/17/24, LPA observed an unlogged medication, vitamin D3 in the medication bin for R-1. On 6/17/24, interviewed staff-1 and staff-2 (S-1 & S-2). LPA ask, does staff mismanage resident’s medication. Of those interviewed, 2 out of 2 answered no. LPA interviewed resident 1 (R-1). Residents R-2 and R-3 were not available for interview. LPA ask, does staff mismanage resident’s medications, and R-1 answered, no. Based on observations, the department did find sufficient evidence to support allegation. The preponderance of evidence has been met therefore the allegation is Substantiated.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 11-AS-20240613131143
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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202
VISIT DATE: 06/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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24
25
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Allegation: Staff mismanaged resident’s P&I funds

It was reported that P&I records were not available. On 6/17/24, LPA observed resident’s P&I fund records on a clip board hanging on the wall accessible to all. LPA reviewed P&I documents and did not find receipts or records of items purchased. On 6/17/24, interviewed staff-1 and staff-2 (S-1 & S-2). LPA ask, does staff mismanage resident’s P&I funds . Of those interviewed, 2 out of 2 answered no. LPA interviewed resident 1 (R-1). Residents R-2 and R-3 were not available for interview. LPA ask, does staff mismanage resident’s P&I funds, and R-1 answered, no. Based on observations, the department did find sufficient evidence to support allegation. The preponderance of evidence has been met therefore the allegation is Substantiated.

Con'd on 9099-A

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
06/13/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20240613131143

FACILITY NAME:JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTSFACILITY NUMBER:
198200202
ADMINISTRATOR:BEVERLY BRINSONFACILITY TYPE:
735
ADDRESS:14004 DAPHNETELEPHONE:
(310) 560-7975
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY:6CENSUS: 3DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Beverly Brinson, LicenseeTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9

Staff did not keep staff/personnel records on file at the facility
Staff did not keep resident records on file at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13

On 6/17/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced complaint visit to the address listed above. LPA and LPM arrived and spoke to staff, Jerry Brinson and the purpose of the visit was discussed. The Licensee, Beverly Brinson arrived shortly after. LPA was granted access to the facility.


The investigation consisted of the following: On 6/17/24 LPA reviewed: Staff files, resident files, P&I records, the MAR of one resident, toured the facility and interviewed both staff.




The investigation revealed the following:

Con'd on 9099-A
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20240613131143
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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202
VISIT DATE: 06/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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Allegation: Staff did not keep staff/personnel records on file at the facility

It was reported that the staff records were not available. LPA arrived at this facility and spoke with both staff and licensee and observed that staff records were not available. Licensee left and returned with the records. On 6/17/24, interviewed staff-1 and staff-2 (S-1 & S-2). LPA ask, “Does staff keep staff records on file at this facility.” Of those interviewed, 2 out of 2 answered yes. LPA interviewed resident 1 (R-1). Residents R-2 and R-3 were not available for interview. LPA ask, Does staff keep staff records on file at the facility, and R-1 answered, they were not sure. Based on the licensee providing the resident files, the department did not find sufficient evidence to support allegations "Staff did not keep staff records on file at the facility.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff did not keep resident records on file at the facility

It was reported that the client charts were not available. LPA arrived at this facility and spoke with both staff and licensee and observed that client records were not available. Licensee left and returned with the records. On 6/17/24, interviewed staff-1 and staff-2 (S-1 & S-2). LPA ask, “Does staff keep resident records on file at this facility.” Of those interviewed, 2 out of 2 answered yes. LPA interviewed resident 1 (R-1). Residents R-2

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20240613131143
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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202
VISIT DATE: 06/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
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12
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and R-3 were not available for interview. LPA ask, Does staff keep staff records on file at the facility, and R-1 answered, they were not sure. Based on the licensee providing the resident files, the department did not find sufficient evidence to support allegations "Staff did not keep resident records on file at the facility.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Based on interviews, the preponderance of evidence has been met therefore the allegation is Substantiated.



Deficiencies were issued for this visit.

An exit interview was conducted, plans of correction were developed, and a copy of the LIC 9099 was provided to Licensee, Beverly Brinson.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20240613131143
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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2024
Section Cited
CCR
80087(g)
1
2
3
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7
80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Please review regulation cited for this violation and submit a written understanding of the regulation and submit to LPA Shirley via fax or email to felisa.shirley@dss.ca.gov by POC due date of 7/3/24.
8
9
10
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Based on observation, the Licensee did not comply with the section cited above in which having exposed toxins such as powered detergent and lysol poses as possible health and safety risk to persons in care.
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Type B
07/03/2024
Section Cited
CCR
80075(5)(C)
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80075 Health Related Services (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken and the client's response.

This requirement is not met as evidenced by:
1
2
3
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7
Please review regulation cited for this violation and submit a written understanding of the regulation and submit to LPA Shirley via fax or email to felisa.shirley@dss.ca.gov by POC due date of 7/3/24.
8
9
10
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Based on observation and interview, the Licensee did not complt with the section cited above in which having unapproved and unlogged medications can pose an immediate health and safety risk to persons in care.
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9
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14
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: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20240613131143
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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2024
Section Cited
CCR
80026(e)(A)
1
2
3
4
5
6
7
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (e)Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash. (A)Documentation of such transactions shall be maintained in the facility.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Please review regulation cited for this violation and submit a written understanding of the regulation and submit to LPA Shirley via fax or email to felisa.shirley@dss.ca.gov by POC due date of 7/3/24.
8
9
10
11
12
13
14
Based on observation and interview the Licensee did not comply with the section cited above in which having personal and confidential records exposed and accessable to all, and not keeping record of purchases made with P&I funds can pose as a personal right risk to persons in care.
8
9
10
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12
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14
1
2
3
4
5
6
7
1
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3
4
5
6
7
1
2
3
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5
6
7
1
2
3
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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: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8