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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320417
Report Date: 08/04/2026
Date Signed: 08/04/2026 02:55:45 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
12/01/2025 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251201153121
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: DATE:
08/04/2026
UNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Esperanza Naaktgeboren (Administrator)TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident sustained an unstageable pressure injury due to staff neglect/lack of supervision.
INVESTIGATION FINDINGS:
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On 08/04/2026 at 08:25, the department conducted an subsequent visit at this facility to deliver the complaint findings for the allegation above. During today’s visit, LPA met with Esperanza Naaktgeboren (Administrator) and explained the purpose of the visit.

On 12/02/2025, at 8:55am, the department initiated an unannounced complaint investigation for the allegations listed above. During the initial visit, the department met with Joel Niblett (Administrator) and the purpose of the visit was explained.

The department interviewed with Staff (S1-S7) on 12/05/2026 between the hours of 9:21am - 3:00pm, on 12/03/2025 with Administrator (A1) at 10:57am & on 08/04/2026 between the hours of 8:31am - 940am Residents (R2- R10). LPA also requested and received the documents: Staff Roster (dated 11/17/2025), Client Roster (received on 12/02/2025), Resident #1 (R1's) documents such as LIC 601 Identification & Emergency Form (not dated), LIC 602: Physician Report (dated 09/09/2025), Service Plan (dated 09/17/2025), Admission Agreement (dated 09/2025), Medication List (printed 09/06/2025), continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
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-20251201153121
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: 08/04/2026
NARRATIVE
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Outside Agency Service Documentation (dated 09/13/2025 & 11/21/2025), Resident Assessment (dated 09/17/2025), OMNI Wound Physicians (date of service 11/21/2025), Outside Agency(Omni Wound Physicians) /Service Documentation (dated 11/21/2025) and UCI Lakewood Medical Records (dated 11/21/2025)

The investigation revealed the following:
Allegation:Resident sustained an unstageable pressure injury due to staff neglect/lack of supervision

It was alleged that the facility failed to provide adequate care and supervision to a resident, resulting in the development of a significant medical condition identified an unstageable sacral wound on a resident who has a history of Alzheimer’s and dementia.

On 12/03/2025 at 10:57am, the Department interview the former administrator (A1) in regards to the allegation. A1 stated he did not know the resident’s skin-check schedule, did not recall any pressure-injury prevention procedures, did not know when the pressure injury was first observed, and was unaware of any documentation or repositioning logs. A1 repeatedly stated information was “unknown to me,” indicating no direct knowledge of the resident’s wound, monitoring, or care practices.

On 12/02/2025 between the hours of 9:27am - 3:10pm, the department conducted 8 staff regarding the allegation.

3 out of 7 staff confirmed the allegation and stated R1's pressure injury was bleeding and required hospital transfer. S1 reported notifying the LVN several times and stated not being trained for wound care. S2 stated the wound was first observed by another caregiver and that hospice did not respond quickly. S2 explained that the facility cleaned around the wound and covered it with gauze before sending the resident to the hospital. S6 stated repeatedly reported the wound and that Home Health never came to assess it. S6 also stated the medtech did not monitor the wound closely and that documentation between medtechs was often missing.

5 out of 7 staff did not confirm nor deny the allegation and mentioned general care routines such as daily body checks and repositioning is documented. None of 5 staff who did not confirm nor deny the allegation had direct knowledge of the R1's pressure injury.

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

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20251201153121
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: 08/04/2026
NARRATIVE
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On 08/04/2026 between the hours of 8:31am - 9:40am, the Department conducted interviews 10 residents in regards to the allegation.

6 out of 10 residents denied the allegation and stated that stated that staff are responsive, attentive, perform skin checks, and assist with comfort and repositioning when needed. These residents reported staff respond quickly to call-lights, assist with turning or repositioning, check skin regularly, and help when pain or discomfort occurs.

4 out of 10 residents did not confirm nor deny the allegation and stated they are mostly independent with repositioning, occasionally experience delays in receiving assistance, and or were unsure how often staff assist with movement or skin checks.

On 07/26/2026 between the hours of 2:00pm - 3:00pm, the department conducted a records review and observed the following:

R1 was admitted to UCI Health – Lakewood on 11/27/2025 after being transferred from Brittany House due to a sacral wound present for approximately one week, with drainage, worsening erythema, and wound pain.

Prior to hospitalization, the resident was evaluated by OMNI Wound Physicians on 11/21/2025, where the sacrococcygeal wound was identified and categorized as a Stage 4 pressure ulcer. OMNI documented pre-debridement wound measurements of 4.5 cm × 3.0 cm × 0.3 cm, and post-debridement measurements of 4.6 cm × 3.1 cm × 0.4 cm, with a total debrided area of 7.13 cm². OMNI ordered Santyl ointment, silicone bordered foam dressings, an alternating pressure pad/low air loss mattress, and off-loading/turning every 2 hours. Upon hospital admission on 11/27/2025, the wound was documented as an unstageable sacral pressure injury due to slough, thick eschar, and necrotic tissue, measuring approximately 5.0 cm × 4.5 cm.

The wound had progressed to acute hematogenous osteomyelitis of the sacrum (left S2) and sepsis, with positive blood cultures for Staphylococcus epidermidis and wound cultures growing Proteus mirabilis. The resident underwent three debridements: one by OMNI on 11/21/2025, one at UCI Health on 11/29/2025, and a surgical excisional debridement down to fascia/necrotic tissue on 12/05/2025 by General Surgery.

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

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20251201153121
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: 08/04/2026
NARRATIVE
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The resident required broad-spectrum IV antibiotics, nutritional supplementation, and placement on an air-fluidized Envella bed with a Q2-hour turning protocol. Records further indicated the resident’s family was not notified by Brittany House that a sacral wound had developed. Additionally, the resident’s LIC 602A, completed on 09/09/2025, indicated no history of skin breakdown, and documented the resident as ambulatory, able to independently transfer, and not requiring continuous bed care. The hospital documentation stating the resident had been bedbound for approximately nine months prior to admission.

R1 was discharged on 12/13/2025 to Cerritos Vista Skilled Nursing Facility with a Wound VAC in place. Also, effective as of 12/13/2025, R1 is no longer a resident at the facility.

Based on interviews and records reviewed facility staff failed to ensure R1 received proper wound care such as repositing which resulted in the resident developing a stage 4 pressure injury that required medical intervention.



At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code
1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).
An immediate $500 civil penalty assessed.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted with Esperanza Naaktgeboren (Administrator) and a copy of this report was provided with appeal rights.

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

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20251201153121
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: 08/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2026
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition 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.
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Licensee shall ensure all staff receiving training on personal rights, provisions for providing care and supervision and resident care plans. License shall submit proof of training by POC due date. Email proof to LPA Brown at Zina.Brown@dss.ca.gov
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This requirement was not met as evidenced by: Based on interviews and records review facility staff failed to reposition R1 as required by residents Home Health which resulted in the R1 developing a stage 4 pressure injury. This poses an immediate health & safety risk to residents in care.
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An immediate $500 civil penalty assessed.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5