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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320417
Report Date: 12/10/2024
Date Signed: 12/12/2024 12:09:47 PM

Document Has Been Signed on 12/12/2024 12:09 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:BRITTANY HOUSEFACILITY NUMBER:
198320417
ADMINISTRATOR/
DIRECTOR:		WINKELBAUER, SHANEFACILITY TYPE:
740
ADDRESS:5401 E CENTRALIA STTELEPHONE:
(562) 421-4717
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 170CENSUS: 57DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:18 AM
MET WITH:Marcus Falani, Resident Care CoordinatorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 12/10/2024 at 8:18am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection (due February 2025). LPA met with Marcus Falanai, Resident Care Coordinator and the purpose of the visit was discussed. Facility is licensed to serve age range 60 and over which is approved for 170 non-ambulatory of which 24 may be bedridden (bedroom 301 - 303, 307 - 308, 311-314 may have 2 bedridden) and bedroom #304-306 and 309 may have 1 bedridden only with a waiver granted for hospice care for ten (10). There are (50) residents are diagnosed with dementia, (9) residents receiving home health, (10) residents receiving hospice care services and (1) resident receiving palliative care. The last fire inspection was completed on 05/08/2024. The facility does not handle any of the residents’ money. The facility annual fee is $$2,311.00 which is due on 02/09/2025. LPA provided pin #773699 if facility choose to make facility annual payment online.

The facility a single story building consisting of: (142) resident bedrooms, (43) Full bathrooms, kitchen, (4) dining area, laundry room, medication room and (10) outdoor shaded patio areas. LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 108.0F -112.3.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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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: BRITTANY HOUSE
FACILITY NUMBER: 198320417
VISIT DATE: 12/10/2024
NARRATIVE
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A review of (10) residents service files, (10) staff personnel files and (10) Medication Administration Records (MAR) and did observe discrepancies at the time of visit.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

-Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies:
On 12/10/2024 at 1:45 pm while LPA was conducting a tour of the physical plant, LPA reviewed and observed:

  • 4 out 10 staff (Staff #1, Staff #4 - Staff #6) with no CPR/First Aid Certification.
  • 8 out of 10 staff did not have a LIC 503 Health Screening with TB Test results.
  • 10 out of 10 residents medication was not listed on the MAR, empty and or not check off by staff on consecutive days.
  • LPA conducted a file review of the 5 out of 10 residents files and did not observe an Needs and Services Plan within 30 days after admission date.

An exit interview was conducted, and a copy of Report and Appeal Rights provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/12/2024 12:09 PM - It Cannot Be Edited


Created By: Zina Brown On 12/10/2024 at 04:04 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: BRITTANY HOUSE
FACILITY NUMBER: 198320417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
87457 (c)(1)
Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1)The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the facility did not comply with the section cited above for 5 out of 10 clients which poses a potential health, safety or personal rights risk to persons in care.
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POC Due Date: 01/07/2025
Plan of Correction
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The facility will submit proof of needs and appraisal plan for resident #1 - #4 and resident #10, via email zina.brown@dss.ca.gov by POC due date.
Type B
Section Cited
CCR
87465(a)(4)
87465(a)(4) Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as during medication reviews, LPA observed documentation on the MAR residents missed taking medication throughout the week and or no MAR documentaion for new residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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The executive director will ensure an in-service training regard medication documentation is completed by POC due date and provide proof of in-service training for all staff via email at zina.brown@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/12/2024 12:09 PM - It Cannot Be Edited


Created By: Zina Brown On 12/10/2024 at 04:12 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: BRITTANY HOUSE
FACILITY NUMBER: 198320417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview record review, the licensee did not comply with the section cited above in 4 out of 10 staff have expired and or no First Aid/CPR Certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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The facility will submit proof of completed First Aid/CPR certification for Staff #1 and Staff #4 - Staff #6 via email zina.brown@dss.ca.gov by POC due date.

Type B
Section Cited
CCR
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in 7 out of 10 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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The facility will submit proof of LIC 503 Health Screening with TB results for Staff #2 - Staff #4 and Staff #6 - Staff #9 via email zina.brown@dss.ca.gov by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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