<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320417
Report Date: 08/31/2024
Date Signed: 08/31/2024 06:27:41 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, 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
08/16/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240816151317
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: 74DATE:
08/31/2024
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Laurie RiffelTIME COMPLETED:
04:37 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notify authorized representative of incident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Med-Ted (S6:Laurie Riffel). LPA stated the purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: A health and safety visit was conducted 08/21/24 and 08/23/24. A toured the facility’s physical plant. A review of documents: Residents’ Roster (dated: 08/21/24); Staff Roster & Work Schedules (dated: 08/21/24); Admissions Agreement (dated: 08/10/20); Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20); and

(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
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 9
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
08/16/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240816151317

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: 74DATE:
08/31/2024
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Laurie RiffelTIME COMPLETED:
04:37 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injury while in care.
Staff did not provide a safe environment for resident.
Staff left resident in soiled clothing/bedding.
Staff are not ensuring resident's hygiene needs are met.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Med-Ted (S6:Laurie Riffel). LPA stated the purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: A health and safety visit was conducted 08/21/24 and 08/23/24. A toured the facility’s physical plant. A review of documents: Residents’ Roster (dated: 08/21/24); Staff Roster & Work Schedules (dated: 08/21/24); Admissions Agreement (dated: 08/10/20); Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20)

(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 11-AS-20240816151317
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: BRITTANY HOUSE
FACILITY NUMBER: 198320417
VISIT DATE: 08/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Nurses Notes (dated: 08/10/20 – 11/12/23); Shower Scheduled (dated: 08/01/24-08/231/24); Vital Sings Records; Weight Records; and Podiatric Evaluation and Treatment (dated: 11/02/20 – 06/21/23); Los Alamitos Medical Center Medical Records (dated: 08/26/24), and other documents associated with this complaint.

INVESTIGATION REVEALED THE FOLLOWING:

Allegation #2: Resident sustained injury while in care.

The details of the complaint alleged resident #1 (R1) sustained injury while in care. Information provided claimed while (R1) was examined at Los Alamitos Medical Center it revealed (R1) had pressure ulcers.

On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) who denied (R1) had pressure injuries. (A1) stated when (R1) was admitted on 08/10/20 an examination of the body was performed and it indicated that old scars on the buttocks, otherwise skin was clear and intact. Whatever sore that (R1) had from the skilled nursing facility Broadway by the Sea had healed. (S3-S5) who had direct contact with (R1) as primary caregivers refuted this claim. (S3-S5) claimed body checks are performed daily and there were no indications of skin tears, lacerations, or bed sores during (R1) care at this facility. (A1-S1-S5) verified that (R1) did not have any injuries due to falls or accidents.



On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) who verified to have had no pressure injuries while being cared for at this facility.

On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6), claimed that residents have not sustained pressure injuries while in care at this facility. (W1) claimed Los Alamitos Medical Center made no mention of a bed sore on (R1), however, Kaiser Permanente did specify (R1) had pressure injuries.

A review of the Los Alamitos Medical Center Medical Records (dated: 08/26/24) (R1) was examined and it indicated skin had no rashes or redness. There was no indication of pressure ulcers in the gluteal region. Medical records indicated examination consisted of the gluteal area for a colonic diverticulosis procedure that may have later been attributed to a skin tear in the gluteal region.

(Evaluation Report continues LIC 9099-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 11-AS-20240816151317
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: BRITTANY HOUSE
FACILITY NUMBER: 198320417
VISIT DATE: 08/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A result of the Department review of (R1’s) service records included: Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20); and Nurses Notes (dated: 08/10/20 – 11/12/23) made no mention of an active pressure ulcers were being treated. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

Allegation #3: Staff did not provide a safe environment for resident.

The details of the complaint alleged the facility staff did not provide a safe environment for resident #1 (R1) while in care. Information provided indicated on 06/06/24, (R1) was left in bed asleep in the room while the area was cleared of residents for construction. The result of the construction left an overwhelming smell of tar and construction noises taking place near (R1’s) room.

On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) verified that some type of remolding was being constructed in unit 4 where (R1) had a room. (A1) S1-S5) all indicated that all residents were moved to the unit 5 area on time. (A1) indicated that all current residents and their representatives were notified Units 3 and 4 were being repurposed for assisted living and memory care will remain in units 1, 2, and 5 in writing. (S1) verified to have notified authorized representatives of the move from unit 4 to unit 5 and construction of unit 4. (S1-S5) said that (R1) remained in the room while the other residents were moved to unit 5. (S1-S4) claimed on 06/06/24, (R1) refused to cooperate and did not want to be relocated to another room. (S1-S5) claimed that (R1) was left in the room for no more than an hour between 11:30 am to 12:30 pm. (R1) eventually agreed to be relocated into a room in unit 5. (S1-S5) stated that (R1) was not abandoned and was not left in unit 4 for more than an hour. (S1-S5) stated the renovation consisted of securing several protections plastic covered to prevent noise, smell, and dust as barriers. (S1-S5) claimed that the renovation of the facility was intended to ensure the safety and health of all residents.

On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) able to recall some of the remolding and were removed from the area timely. (R4-R6) claimed they did feel safe and did not feel any discomfort during the renovation.
(Evaluation Report continues LIC 9099-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 11-AS-20240816151317
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: BRITTANY HOUSE
FACILITY NUMBER: 198320417
VISIT DATE: 08/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6) verified notification from staff was received by telephone. (W3-W6) reported not having any concerns for the health and safety of residents while reconstruction was conducted. Based on the information collected, there is insufficient evidence to corroborate the allegation mentioned above.

Allegation #4: Staff left resident in soiled clothing/bedding.
Allegation #5: Staff are not ensuring resident's hygiene needs are met.

The details of the complaint alleged the facility staff were negligent in resident #1 (R1’s) care. It was reported the attention (R1) receives is a concern. (R1) has been seen in dirty and stained clothing. (R1) does not appear clean and unkempt. On multiple occasions, (R1) has been seen in wet clothing and bedding.

On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) stated these allegations are not accurate. (S1-S5) who have direct care with (R1) reported, (R1) is monitored for repositioning and diaper changes every two hours or as needed. All three shifts regularly perform incontinent services after meals. (R1) is scheduled to shower weekly on Sunday and Thursday. (S3-S5) are primary caregivers to (R1), denied (R1) has been left in stained or soiled clothing and bedding. According to (S1-S5), maintaining good personal hygiene is vital to prevent ill health, and (R1) was provided the care and services daily. (S1-S5) claimed that there were occasions when it was challenging to care for when (R1) refused to receive assistance with hygiene and grooming care services from staff. The staff will attempt to redirect the (R1) or return with a different staff to assist with basic care services. (S1-S5) claimed they are respectful of (R1’s) rights and (R1) has the right to refuse services as well. (S1) stated Progress Notes (aka Nurses Notes) were used to document and track the progress of the resident’s condition over time. (S1) claimed progress notes were only available for (R1) from 08/10/20 – 11/12/23. The Brittany House's new management has not mandated the facility to continue with Progress/Nurse charting and does not have current records.

On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) claimed not to have concerns with their clothing appearance nor have been left in soiled diapers or bedding.

(Evaluation Reports continue LIC 9099-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 11-AS-20240816151317
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: BRITTANY HOUSE
FACILITY NUMBER: 198320417
VISIT DATE: 08/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6) reported having no issues or concerns with the resident’s hygiene. The residents were found in presentable conditions and appearance in clothing when visits were conducted at the facility.

A result of the Department review of (R1’s) service records included: Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20); and Nurses Notes (dated: 08/10/20 – 11/12/23); Shower Scheduled (dated: 08/01/24-08/231/24); Vital Signs Records; Weight Records; and Podiatric Evaluation and Treatment (dated: 11/02/20 – 06/21/23) revealed that hygiene practices were included in daily living activities and services. Based on the information collected, there is insufficient evidence to support the allegations mentioned above.

Between 08/23/24 - 08/29/24, the Department made several attempts to interview resident #1 (R1) by telephone who is now recovering at Heritage Rehabilitation Center. (R1) refused to engage in full conversation.

Based on the evidence gathered interviews conducted, and analysis of records, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations of NEGLECT/LACK OF CARE AND SUPERVISION: “Resident sustained injury while in care", “Staff did not provide a safe environment for resident", “Staff left resident in soiled clothing/bedding”, and “Staff are not ensuring resident's hygiene needs are met” are found to be UNSUBSTANTIATED.

An exit interview was conducted with Laurie Riffel, and a hard copy of the report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 11-AS-20240816151317
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: BRITTANY HOUSE
FACILITY NUMBER: 198320417
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2024
Section Cited
CCR
87705(b)(1)
1
2
3
4
5
6
7
87705 Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia…(1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator…when a resident’s behavior or condition changes.
1
2
3
4
5
6
7
Licensee/Administrator will review Title 22 Sec. 87705 and agreed to provide training to staff pertaining caring for resident with dementia. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to notify the responsible person/conservator for (R1) when (R1) was hospitalized on 08/05/24. This violation poses a potential health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
09/14/2024
Section Cited
CCR
87211(B)(D)
1
2
3
4
5
6
7
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident...
1
2
3
4
5
6
7
Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCL Reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with an incident with (R1) change in condition and hospitalization on 08/05/24. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
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.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 11-AS-20240816151317
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: BRITTANY HOUSE
FACILITY NUMBER: 198320417
VISIT DATE: 08/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Nurses Notes (dated: 08/10/20 – 11/12/23); Shower Scheduled (dated: 08/01/24-08/231/24); Vital Signs Records; Weight Records; and Podiatric Evaluation and Treatment (dated: 11/02/20 – 06/21/23); Los Alamitos Medical Center Medical Records (dated: 08/26/24), and other documents associated with this complaint.

INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff did not notify authorized representative of incident.

The details of the complaint alleged facility staff failed to notify the authorized representative of an incident involving resident #1 (R1) on 08/05/24. Information provided stated (R1) was transported by Emergency Medical Services (EMS) to Los Alamitos Medical Center at 06:00 pm. (R1's) authorized representatives were notified by the hospital's medical physician at 9:30 pm that (R1) needed a medical procedure.



Investigation revealed resident #1 (R1) was admitted at Brittany House on 08/10/20, according to the Admission Agreement (dated: 08/10/20). (R1) was a former resident at Broadway by the Sea. (R1) remained as a resident at Brittany House from 08/10/20 through 08/21/24. On 08/05/24, (R1) was admitted to Los Alamitos Medical Center through 08/08/24 and was transferred to Kaiser Permanente South Bay Medical Center and then to Heritage Rehabilitation Center where (R1) is currently a resident.

On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) who verified to know about (R1’s) emergency admission at Los Alamitos Medical Center. Four (4) out of six (6) admitted (R1’s) hospitalization on 08/05/24 did not account for notifying the authorized representatives. (2) two out of six (6) admitted to the facility failed to notify Community Care Licensing (CCL) with an Unusual Incident/Injury Report LIC 624 of (R1’s) hospitalization on 08/05/24. (S1) claimed the staff responsible for dispatching (EMS) was a new staff and unintentionally failed to follow proper procedures.

On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) who verified that they were informed of any changes in health condition.

(Evaluation Report continues LIC 9099-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 11-AS-20240816151317
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: BRITTANY HOUSE
FACILITY NUMBER: 198320417
VISIT DATE: 08/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6), confirmed to have received notice of any changes in the resident’s condition.

Based on the evidence gathered interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION resulted in " Staff did not notify authorized representative of incident" is found to be SUBSTANTIATED.

Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.

An exit interview was conducted with Laurie Riffel, and a hard copy of the report along with appeal rights.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9