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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200202
Report Date: 09/17/2025
Date Signed: 09/24/2025 10:27:53 PM

Document Has Been Signed on 09/24/2025 10:27 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: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:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Beverly Brinson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 9/17/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual. LPA was met by the Administrator, Beverly Brinson and explained the purpose of today’s visit. The facility has a census of 3. 1 client is currently in the hospital.

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, patio, garage used for storage and laundry area is located in the kitchen. Facility maintains all required posting throughout the facility.

LPA Shirley and Beverly walked through the kitchen and all appliances were in good working order. Knives and medications were locked and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured between 105 and 120 degrees Fahrenheit.

Bedrooms 1 thru 3 are occupied by clients and contain the mandated furniture. The (2) bathrooms are clean and operational. The 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.

LPA Shirley and Beverly walked through all common areas. In the living room, kitchen, and 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 are (2) charged fire extinguishers located in the kitchen and in the hallway. There is a patio table in the backyard with an umbrella for shade. The backyard is clean and clear of obstructions and hazards and there are no bodies of water present.

Con'd on 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: JIMMIE RUTH'S RESIDENTIAL FACILITY FOR ADULTS
FACILITY NUMBER: 198200202
VISIT DATE: 09/17/2025
NARRATIVE
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During file review LPA Shirley observed that (2) clients did not have a medical assessment. LPA also observed that (1) client did not have his TB test results available. During review of medication, LPA observed medication still in the bubble pack for 9/15 and 9/16 but marked as dispensed in the Medication Administration Record, (MAR).

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.



An exit interview was conducted, Plans of Corrections were discussed and a copy of this report and appeals rights were and left with the Administrator, Beverly Brinson whose signature on this form confirms receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Felisa Shirley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/24/2025 10:27 PM - It Cannot Be Edited


Created By: Felisa Shirley On 09/17/2025 at 02:29 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: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.1(c)(1)
85068.1 Admission Procedures
(c) Prior to accepting a client for care and supervision, the person responsible for admissions shall: (d) The facility shall obtain the medical assessment

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which clients Austin Berry and Jaylen Brinson did not have a medical assessment on file, which poses a potential health, safety risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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The licensee shall obtain medical assissments for both clients by POC date of 10/1/2025. Please fax copies of medical assessments to LPA Felisa Shirley at 424-544-1016 or email to felisa.shirley@dss.ca.gov.
Type B
Section Cited
CCR
80069(c)(1)
80069 (c)(1) Client Medical Assessment
(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 Austin Berry did not have record of TB test result on file which poses as a potential health and safety risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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The Licensee shall provide proof of TB test results and fax to LPA Felisa Shirley at 424-544-1016 or email to felisa.shirley@dss.ca.gov by POC date of 10/1/2025.
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: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/24/2025 10:27 PM - It Cannot Be Edited


Created By: Felisa Shirley On 09/17/2025 at 04:24 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: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(10)
80070 (b)(10) Client Records
(b) Each record must contain information including, but not limited to, the following:
(10) Record of current medications, including the name of the prescribing physician and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in which client Daniel Jones had medications in the bubble pack but initialed as dispensed in the Medication Administration Record, (MAR), which poses as a potential health and safety risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Licensee shalll conduct an in-service training for staff and provide copy of training to LPA Felisa Shirley and fax to 424-544-1016 or email to felisa.shirley @dss.ca.gov by POC date of 10/1/25.
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: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
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