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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200202
Report Date: 11/20/2024
Date Signed: 11/22/2024 10:48:07 AM

Document Has Been Signed on 11/22/2024 10:48 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:JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTSFACILITY NUMBER:
198200202
ADMINISTRATOR/
DIRECTOR:		BEVERLY BRINSONFACILITY TYPE:
735
ADDRESS:14004 DAPHNETELEPHONE:
(310) 560-7975
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 3DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Beverly Brinson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 11/20/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Beverly Brinson and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 18 thru 59 years old.

LPA reviewed all resident files and found that they did not contain all required documents. LPA reviewed three (3) staff files and found they did not contain all required documents, training, and certification. During file review, LPA did not observe the surety bond.

LPA Felisa and Beverly toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) client bedrooms, (2) bathrooms, living room, kitchen, dining area, and patio. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Beverly toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored in the file cabinet located in the dining area. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods.

The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202
VISIT DATE: 11/20/2024
NARRATIVE
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LPA Shirley and Beverly walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, and there are no bodies of water present.


An exit interview was conducted, and a copy of this report was provided to Caregiver, Jerry Brinson.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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Document Has Been Signed on 11/22/2024 10:48 AM - It Cannot Be Edited


Created By: Felisa Shirley On 11/20/2024 at 03:38 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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(b)
80025 Bonding
(b) All Licensees, other than governmental entities, who are entrusted to care for and control client's cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records reviewed, the facility's Administrator did not obtain a Surety Bond which poses as a potentional personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator must provide a copy of Surety Bond to CCLD via fax or email by POC due date of 12/18/24. Proof of Corrections can be emailed to felisa.shirley@dss.ca.gove or fax to 424-544-1016.
Type B
Section Cited
CCR
87412(c)
87412 Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review, the Administrator did not provide records for required trainings in the personnel files which poses as a potential safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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The Administrator shall provide copies of required trainings and CPR certifications to CCLD and submit proof to LPA Felisa Shirley via fax to 424-544-1016 or email, felisa.shirley@dss.ca.gov by POC correction date of 12/18/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


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Page: 3 of 5
Document Has Been Signed on 11/22/2024 10:48 AM - It Cannot Be Edited


Created By: Felisa Shirley On 11/20/2024 at 04:00 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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in which Administrator did not update staff nor clients records, which poses a potential safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator shall update all clients and staff records with required documents. Administrator must provide proof to CCLD by POC due date of 12/18/24. Proof of corrections can be emailed to felisa.shirley @dss.ca.gove or fax to 424-544-1016.
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 interviews and records reviewed, the licensee did not comply with the section cited above in which the Administrator failed to provide TB test results to CCLD, which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Administrator shall meet with Austin Berry, parents and Service Cooridinator to plan a way to have client TB tested and submit proof to CCLD via email or fax by POC due date of 12/18/24. Proof of corrections can be emailed to felisa.shirley@dss.ca.gove or fax 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.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/22/2024 10:48 AM - It Cannot Be Edited


Created By: Felisa Shirley On 11/20/2024 at 04:00 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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 interviews and records review the licensee did not comply with the section cited above in which there is no CPR training for either of the three staff, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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The administrator shall submit proof of CPR training to CCL by POC date of 12/18/24. Proof of Correction can be submitted by email to felisa.shirley@dss.ca.gov or fax to 424-544-1016.
Type B
Section Cited
CCR
85064.2(g)
(g) Certificates issured under this Section shall be renewed every two(2) years provided the certificate holder has complied with all renewal requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the Administrator certificate has expired which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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The Administrator shall provide a valid Administrator certificat or proof of payment and submit proof to LPA, Felisa Shirley via fax 424-544-1016 or email, felisa.shirley@dss.ca.gov by POC correction date of 12/18/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


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