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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320417
Report Date: 03/21/2024
Date Signed: 03/21/2024 05:45:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2024 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20240315115358
FACILITY NAME:BRITTANY HOUSEFACILITY NUMBER:
198320417
ADMINISTRATOR:WINKELBAUER, SHANEFACILITY TYPE:
740
ADDRESS:5401 E CENTRALIA STTELEPHONE:
(562) 421-4717
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:170CENSUS: 66DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Mandy TaylorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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The facility admitted a resident with prohibited health condition.
The facility operates beyond conditions and limitations specified on the license.
INVESTIGATION FINDINGS:
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On 03/21/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Administrator, Mandy Taylor, and the purpose of today’s visit was explained.

During today's visit, LPA toured the facility, interviewed Staff (S1-S8), interviewed Residents (R2-R7), and received documents pertinent to the investigation. The documents received and reviewed are the Staff Roster, Resident Roster, Plan of Operation, resident Physicians Report, visitor logs, Preplacement Appraisal, and Resident Admission Agreement.

The investigation revealed the following:

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
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 5
Control Number 11-AS-20240315115358
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 198320417
VISIT DATE: 03/21/2024
NARRATIVE
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Allegation: The facility admitted a resident with a prohibited health condition.
It is alleged a resident was admitted and moved into the facility, in the beginning of March 2024, with a communicable disease prohibited health condition.
During interviews with staff (S1-S8), they were asked if a resident with a prohibited condition was admitted, seven (7) out of eight (8) stated Resident R1 was admitted to the facility with a prohibited health condition. During an interview with the Administrator (S1) stated they were unsure if an exemption was submitted to Community Care Licensing (CCL). Additionally, S1 stated when they became employed at the facility, on March 18,2024, they had R1 placed on home health for the care of the condition, and since that time R1 has been cleared, by a physician, of the prohibited health condition. During an interview with S2 stated that once they found out R1 had a prohibited health condition, staff took precautions such as isolating R1, placing a PPE cart outside the room for staff to use. During file review of Resident R1, LPA observed the facility was informed of R1’s diagnosis of the prohibited health condition via fax on March 12, 2024, at 8:37AM PDT. R1 was admitted to the facility on March 12, 2024, after a diagnosis of the prohibited health condition. During interview with residents (R2-R7) six (6) out of six (6) stated they were unsure if the are any residents with a prohibited condition.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20240315115358
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 198320417
VISIT DATE: 03/21/2024
NARRATIVE
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Allegation: The facility operates beyond condition and limitations specified on the license.
It is alleged a client has come to the facility and uses it as a daycare and is participating in activities and meals then is picked up at 5:30pm.
During interviews with staff (S1-S8), they were asked if there is a client who comes in and participates in daily activities and has meals, four (4) out of eight (8), stated C1 has been at the facility a few times and participated in activities. During an interview with S2, stated C1 has been in the facility twice when C1’s spouse has things they need to do. Additionally, S2 stated C1 will be a resident at the facility eventually but the family is not ready to place them here yet. S2 stated C2 receives minimal assistance while here and has been charged for the days they participated in the program. During file review, LPA observed on the Visitor Log, C1 was signed in on 03/06/24 at 8:30am, and on 03/15/24 at 8:25am till 6pm. During interviews with residents (R2-R7), six (6) out of six (6) stated they have no knowledge or concern of C1 coming in to participate in activities or meals.
During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

Two deficiencies were cited on the attached LIC9099-D.
An exit interview was conducted with Maintenance Director, Juan Talavera, and a copy of this report and the appeals rights were provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20240315115358
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 198320417
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2024
Section Cited
CCR
87615(a)(4)
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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not ve admitted or retained in a residental care faclity for the elderly: (4) Staphylococcus aureus ("staph") infection or other serious
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Administrator will review Tittle 22, Division 6 Chapter 8 Article 11 Health Related Services and conditions. Adminsitrator will submit a signed letter to LPA upon completion stating it was reviewed. Administrator will submit an excemption request to CCL and a Care Plan for the R1 by the POC.
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infection.
This regulation was not met based on evidence by:
Record review and interviews, the licensee failed to ensure resident R1 did not have a phohibited health condition
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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.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20240315115358
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BRITTANY HOUSE
FACILITY NUMBER: 198320417
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
87204(a)
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87204Limitations-Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum numbe of persons who my receive sedrvice at any one time. An exceptio my be made in the case
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Administrator will review Title 22, 87204 Limitations and submit a signed letter stating it has been reviewed by POC. Administrator will ensure C1 no longer being left at the facility unless a resident.
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of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity,
This regeulation was not met based on: Interviews and file review, C1 has paid to come and stay at the faclitily during the day, meals and services are porvided.
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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.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5