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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320417
Report Date: 11/24/2025
Date Signed: 11/24/2025 03:16:28 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
11/18/2025 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251118115055
FACILITY NAME:BRITTANY HOUSEFACILITY NUMBER:
198320417
ADMINISTRATOR:JOEL NIBLETTFACILITY TYPE:
740
ADDRESS:5401 E CENTRALIA STTELEPHONE:
(562) 421-4717
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY:170CENSUS: 130DATE:
11/24/2025
UNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Joel NiblettTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not address resident's change of condition.
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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On 11/24/25, at 9:20am, the department conducted an initial complaint visit to the facility and was greeted by Joel Niblett, Executive Director. The department explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation(s) mentioned above.

The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S5), witness (W1), and residents (R1-R10). The department received the following facility documents: Resident Roster (Date: No Date), Staff Roster (Dated: 11/17/2025), Admission Agreement (Dated: 08/14/2025 ), Face Sheet/ID Emergency information (Dated:11/24/2025, 08/13/2025), Physician’s Report (Dated: 08/12/2025), Appraisal & Needs Service Plan (Printed On: 11/24/2025), Incident Report (Dated: None), Preplacement Appraisal Information (Dated: 08/11/2025), and Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) from the facility.

Report Continued On LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
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 4
Control Number 11-AS-20251118115055
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: 11/24/2025
NARRATIVE
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The investigation revealed the following: Allegation #1-Staff did not address residents’ change of condition.

The details of the complaint alleged that the facility did not address the residents’ change of condition. It was reported that the resident had bandages wrapped around their toe, when it was inquired why, staff stated that perhaps the residents’ shoes were too tight and probably caused the blistering on their foot. Subsequently, without medical attention, the residents’ foot became swollen, and their toe became infected and needed to be amputated. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S5), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that they notified the nurse (LVN) about the residents’ swollen foot and contacted the family member. They stated that the nurse is responsible for getting medical assistance for the residents. One staff member stated that the resident (R1) told them that their foot was swollen and needed assistance; staff stated that they advised the LVN of the problem. Staff also stated that residents are checked on every one to two hours a day to assess their condition.

The department interviewed residents (R1-R10) about the allegation and 6 of 10 residents that were interviewed stated that they believed the staff would not know if they had a change in their condition. When asked why, they stated that they believe they need more training. The department also interviewed witness (W1) about the incident, and they stated that the nursing team never called or had communication with them regarding R1, even when (W1) discovered that R1s foot was swollen and bandaged.

The department reviewed the Appraisal & Needs Service Plan (Printed On: 11/24/2025), Physician’s Report (Dated: 08/12/2025), and the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) and observed that the Med Tech Communication Log noted that first aid was applied because R1s foot was swollen on 10/25/2025, 10/29/2025, 10/30/2025, and 11/1/2025. The log noted that the LVN and family member were notified. However, medical services were not notified to address R1s change in condition; resulting in R1s toe becoming infected and amputated. Additionally, the department did not receive an incident report detailing the hospital visit, amputation, nor the swollen foot.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not address residents’ change of condition, is found to be Substantiated. Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D.

Report Continued On LIC9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20251118115055
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: 11/24/2025
NARRATIVE
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Allegation #2- Staff did not seek medical attention for resident in a timely manner.

The details of the complaint alleged that the facility did not seek timely medical attention for the resident. It was reported that the residents’ foot became swollen and their toe became infected and needed to be amputated, as a result of inaction by the facility. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S5), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that they told the nurse about the resident and they were responsible for getting medical services involved, if appropriate. Staff stated that they believed the resident was going to get medical services for their swollen foot.

The department interviewed residents (R1-R10) about the allegation and 4 of 10 residents that were interviewed stated that staff have sought medical attention for them in a timely manner in the past. The department interviewed witness (W1) about the allegation, and they stated that they believed the facility did not seek medical attention for the resident in a timely manner. Additionally, they stated that they were not made aware of the condition before it got to the point where R1s toe needed to be amputated.

The department could not review the LIC624 Unusual Incident Report about the swollen foot or subsequent hospitalization because the facility failed to submit it to Community Care Licensing Division within seven days of the occurrence. The department did review the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) but it did not specify that medical services were notified, or any action taken on behalf of the resident.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not seek medical attention for resident in a timely manner, is found to be Substantiated. Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D.

Deficiencies were issued and plans of corrections were discussed.

Note: *Citations that are not cleared by the POC due date of 12/05/25 will have a $100 fine assessed for each day that the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared.

An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20251118115055
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: 11/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2025
Section Cited
CCR
87466
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Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental… functioning and that appropriate assistance is provided when such observation reveals unmet needs. When…deterioration …are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
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The administrator will create a plan of correction to ensure that observations of residents are conducted when significant change in the resident’s condition is observed and review and conduct in-service training for staff of 87466 Observation of Resident. In-service training with signatures of staff and plan of corrections will be submitted prior to POC due date of 12/05/25, via email, to perry.scott@dss.ca.gov to avoid monetary penalties.
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Based on interviews and record reviewed, the licensee failed to ensure that appropriate assistance was provided to R1 when changes in their physical condition were found (swelling in foot and toe) resulting in the toe being amputated. Which poses a potential risk to the health, safety and personal rights of the resident in care.
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Type B
12/05/2025
Section Cited
CCR
87211(a)(B)(D)
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87211(a)(B)(D) 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... This requirement was not met as evidenced by:
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The Licensee shall submit a serious incident report LIC624 for R1 about the swelling of their foot and toe, and the hospitalization that resulted in the resident having to have their toe amputated because of infection. The report shall be submitted prior to POC due date of 12/05/25, via email, to perry.scott@dss.ca.gov to avoid monetary penalties.
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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 the incident for R1 that resulted in hospitalization and amputation of R1s toe. 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.
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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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4