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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320417
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:31:25 AM

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
09/24/2024 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20240924105844
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: 67DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Mandy TaylorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff do not report incidents to Community Care Licensing.
INVESTIGATION FINDINGS:
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On 10/02/24 at 9:00 am, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegation above. LPA met with Executive Director (ED) Mandy Taylor as the purpose of today’s visit was explained.

The investigation consisted of the following: On 10/02/24 LPA obtained copies of staff and resident rosters, and the following documents for R1: Emergency ID from, facesheet, admission agreement, durable power of attorney, physicians report, POLST, and needs and service plan. On 10/02/24 LPA conducted interviews with ED and staff #1 (S1).

The investigation revealed the following:
Allegation- Staff do not report incidents to Community Care Licensing.
It is being alleged that the facility does not submit incident reports for the death of R1.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
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 3
Control Number 11-AS-20240924105844
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: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2024
Section Cited
CCR
87211(a)(B)(D)
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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...This requirement is not
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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 Lizeth.villegas@dss.ca.gov
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 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 the death of (R1) . 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: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240924105844
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: 10/02/2024
NARRATIVE
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On 10/02/24 LPA conducted interview with Executive Director (ED) regarding the above allegation, ED confirmed the allegation above. Per ED, an employee who is no longer employed at the facility was in charge of submitting SIRs and ED is unsure why the SIR was not submitted. On 10/02/24 LPA conducted interview with staff #1 (S1) regarding the allegation above, 1 of 1 staff interviewed confirmed that there was no incident report submitted for the death of R1 as a previously employed staff who was in charge of submitting reports to the licensing department did not complete the required report. S1 continued to report that S1 is now the employee responsible for submitting incident reports to the licensing department.

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

Exit interview conducted, appeal rights explained, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3