BRITTANY HOUSE

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on records review and interviews conducted the facility failed to request an exception from Licensing when R1 developed a Stage 4 pressure injury, which is a prohibited health condition. This poses an immediate health & safety risk to residents in care.

Official plan of correction

Licensee shall ensure staff receive training on prohibited health conditions and submit proof of the training to the department by POC due date. Email proof to LPA Brown at Zina.Brown@dss.ca.gov

Deadline recorded: Aug 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on records review and interviews conducted the facility failed to request an exception from Licensing when R1 developed a Stage 4 pressure injury, which is a prohibited health condition. This poses an immediate health & safety risk to residents in care.

Official plan of correction

Licensee shall ensure staff receive training on prohibited health conditions and submit proof of the training to the department by POC due date. Email proof to LPA Brown at Zina.Brown@dss.ca.gov

Deadline recorded: Aug 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(b)(2)

Regulation authority

CCR

What the official deficiency says

87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on interviews and records reviewed, the Licensee/Administrator failed to adhere to Title 22 regulations, by properly ensuring facility staff were providing appropriate care for R1 in accordance with Title 22 regulations, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Licensee will create a plan to ensure that the administrator performs and adheres to their duties and has knowledge of and conform to all applicable laws, rules and regulations. A written statement from the administrator stating they have reviewed and understood Title 22 87405(b)(2) Administrator-Qualifications and Duties. Plan of corrections will be sent to LPA Perry Scott by 02/6/26 at perry.scott@dss.ca.gov to avoid monetary penalties.

Deadline recorded: Feb 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(B)(D)

Regulation authority

CCR

What the official deficiency says

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: 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 that an LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal-rights risk to persons in care.

Official plan of correction

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 1/22/26, via email, to perry.scott@dss.ca.gov to avoid monetary penalties. This citation was cleared during today’s visit.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on observation and interview, 3 of 12 staff are not associated to the facility at the time of unannounced inspection which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The facility shall associate staff: Leticia Velasco, Cristina Valencia & Alma Soto in Guardian and submit proof of being associated with the facility via email zina.brown@dss.ca.gov by POC due date.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, 3 of 12 staff are not associated to the facility as the time of unannounced inspection which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2026 Plan of Correction The facility shall associate staff: Leticia Velasco, Cristina Valencia & Alma Soto in Guardian and submit proof of being associated with the facility via email zina.brown@dss.ca.gov by POC due date.

Official classification

Type B

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above for 6 out of 10 residents who have incomplete registration on the MAR which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Licensee will adhere to Title 22 Reg 87465 at all times. Licensee will ensure shalll receive in-service training by licensed medical profession. Proof of correction must be sent to LPA Zina.Brown@dss.ca.gov

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General: 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 This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above for 1 of 12 staff - no personnel record on file, 2 of 12 staff - no TB Test on file, 3 of 12 staff : no health screening on file & 6 of 12 staff - no CPR on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Licensee will adhere to Title 22 Reg 87411 at all times. Licensee will ensure all staff have complete required documents file records. Proof of correction must be sent to LPA Zina.Brown@dss.ca.gov

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for the water testing in Unit 2 shower Room 101.1F, bathroom in Room 223 tested at 72.8F, & Room 231 water tested at 80.4F, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2026 Plan of Correction Licensee will adhere to Title 22 Reg 87303 at all times. Licensee will ensure that water supply remain in compliance with hot water temperature of not less than 105 degrees F and not more than 120 degree F. Proof of correction must be sent to LPA Zina.Brown@dss.ca.gov *Correction during visit 01/15/26

Official classification

Type B

Official code

87307(2)(B)

Regulation authority

HSC

What the official deficiency says

Personal Accommodations & Service: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in rooms 402 , 412, 214,236, 223, 231, 305 are missing a lamp and in rooms 236 223 231 305 missing chair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Licensee will adhere to Title 22 Reg 87307 at all times. Licensee will ensure that all resident's in care are provided with required furnishing and accomodation. Proof of correction must be sent to LPA Zina.Brown@dss.ca.gov

Official classification

Type B

Official code

1569.626(a)(b)

Regulation authority

HSC

What the official deficiency says

Training Requirement for Direct Care Staff (a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1)Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia... (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care... Deficient Practice Statement Based on observation, interview, & record review the licensee did not comply with the section cited above for all staff who assist resident with activities of daily living do not have the required training to be in compliance with Title 22 Health & Safety Code which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/15/2026 Plan of Correction Licensee shall adhere to H & S 1569.626 and ensure that all direct staff complete the required trianing as stated in H & S 1569.626. Proof of correction must be submitted to LPA Zina.Brown@dss.ca.gov.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 & 4 pressure injuries. Based on records review the facility retained R1, who had a unstageable pressure injury which is prohibited by title 22 regulations. The facility failed to submit an exception request from the department to retain R1.

Official plan of correction

The facility will develop & schedule a mandatory in-service training for all staff on the topic: Prohibited Health Conditions to be in compliance with Title 22 requirements. Also, if necessary the facility will submit any exception requests for Prohibited Health Condition to the department as required. . . upon the residents change in condition to be in compliance with Title 22 regulations. The facility will submit proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016, Attn: Zina Brown, or via email at zina.brown@dss.ca.gov by the POC due date.

Deadline recorded: Dec 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements(a)(1)Each licensee shall submit serious incident reports to. . . the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurance of any of the events This requirement was not met as evidenced by: based observation, LPA observed that the facility did submit a LIC 624 to the department within 7 day of incident occurring.

Official plan of correction

The facility shall will submit a serious incident reports for the incident that occur on 09/09/2025 with the resident who had symptoms of chill and fevers. The report must be fax to 424-544-1016 to department by POC due date.

Deadline recorded: Nov 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Each licensee shall submit serious incident reports to the licensing agency such as the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events. This requirement was not met as evidenced by: LPA observed no LIC 624 Unusual Incident/Injury Report nor a LIC624A Death Report for Resident 1 was not submitted to the department within 7 day of incident occurring

Official plan of correction

The facility will submit a LIC 624 Unusual Incident/Injury Report & a LIC624A Death Report for Resident 1 (R1). Also the facility will conduct an in-service training for Medtechs, Licensed Nurses & Department Directors on Reporting Requirement per Title 22 regulations. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Deadline recorded: Nov 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87623(b)(2)(B)(C)

Regulation authority

CCR

What the official deficiency says

87623 Indwelling Urinary Catheter In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for thefollowing:Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. There should be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed...This requirement was not met as there was no plan in place for catheter care which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Executive director to review section cited and submit a plan on how to get into compliance. Facility will ensure there are care plans available for review, plan should detail what staff will oversee the care.

Deadline recorded: Dec 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on review of records, the licensee did not comply with the section. LPA identified that one staff member did not have a Criminal Clearance Background, Clearance Transfer associated with this facility. This violation poses an immediate health, safety, or personal rights risk to the person in care.

Official plan of correction

Licensee to ensure that all staff, before working in the facility, obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by the POC due date. Proof of Correction due date: 08/22/25. Antonine.Richard@dss.ca.gov

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by: Based on observation and interviews conducted S1 could not locate or find R1 file. This is a safety risk to clients in care.

Official plan of correction

Administrator to move all closed and open resident files to a centeral location which is locked. Administrator to have a sign in sheet for residents files which are pulled by staff.

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

Personnel Records (a) - (h) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:... This requirement was not met as evidenced by: LPA reviewed staff 1-9 files and observed that there were no annual tranings, mectech certifications for S1-S7 This violation poses a potential health, safety, or personal rights risk to residents in care.

Official plan of correction

Joel Niblett-Administrator has agreed to conduct an audit of all staff files monitouring progress daily to esure files are completed with all documents by the POC date. Joel has agreed to provide proof of annual training to all staff members, including medtech trainings . Details of the course prvided and signed by all staff will be emailed to LPA by the POC date of 6/6/2025.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (c) (3)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:... This requirement was not met as evidenced by: LPA observed R1 and R2 medications were not signed as being dispensed and there was medication signed off as being disspensed but in package. This violation poses a potential health, safety, or personal rights risk to residents in care.

Official plan of correction

Joel Niblett-Administrator has agreed to conduct training to all medtecs LVNs on documentation requirements policy and procedures standards by the POC date of 6/6/2025. Proof of traing signed by all staff and certifications will be emailed to LPA by the POC date 6/6/2025.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Each licensee shall submit serious incident reports to the licensing agency such as the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events

Official plan of correction

The facility need submit a serious incident report of the incident that occurred with Resident #6 & Resident #7. Also facility need to review Title 22 Regulations for Reporting Requirements and self certify that all staff read Title 22 Regulations.

Deadline recorded: Apr 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)(1)

Regulation authority

CCR

What the official deficiency says

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 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. .

Official plan of correction

POC Due Date: 01/07/2025 Plan of Correction 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.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 01/07/2025 Plan of Correction 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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/07/2025 Plan of Correction 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.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/07/2025 Plan of Correction 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.