198320417-6-18-2025-11-AS-JHAD-DHTLM6-20250620085213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320417
Report Date: 06/18/2025
Date Signed: 06/18/2025 01:22:13 PM

Unsubstantiated

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
04/01/2025 and conducted by Evaluator Zina Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250401131451

FACILITY NAME:	BRITTANY HOUSE		FACILITY NUMBER:	198320417
ADMINISTRATOR:	WINKELBAUER, SHANE		FACILITY TYPE:	740
ADDRESS:	5401 E CENTRALIA ST		TELEPHONE:	(562) 421-4717
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90808
CAPACITY:	170	CENSUS: 86	DATE:	06/18/2025
		UNANNOUNCED	TIME BEGAN:	08:47 AM
MET WITH:	Joel Niblett, Administrator Designee		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulting in resident being assaulted by another resident while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

This report supersedes report dated 05/08/2025 to include additional information. The complaint investigation findings remain the same.

On 06/18/2025 at 8:47am Licensing Program Analyst (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, LPA met with Joel Niblett, Administrator Designee and the explained the purpose of the visit.

The investigation consisted of the following:
On 04/03/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #6 (S1 - S6) and Resident #1- #6 (R1 – R6). LPA requested copies of the staff roster (dated 01/31/2025) and resident roster, centrally stored medication record (for R7), Service Plans (for R6 - R7), Physician's Order (List of Medication for R6-R7), LIC 602: Physician Report for RCFE, LIC 601 Identification and Emergency Information.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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 3

Control Number 11-AS-20250401131451

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: 06/18/2025

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 06/18/2024, LPA interviewed Staff# 8 - Staff# 10, requested a copy of the LIC 624: Unusual Incident Injury for R1-R2 (dated 12/21/2024) and staff schedule (December 2024).

The investigation revealed the following:
Allegation: Lack of supervision resulting in resident being assaulted by another resident while in care.

On 04/03/2025 between the hours of 12:18pm - 12:28pm, LPA interviewed the Administrator (A1), regarding the above allegation. A1 stated she was unaware of the allegation.

On 04/03/2025 between the time of 9:31am - 12:28pm, LPA interviewed Staff # 1 (S1)– Staff 6 (S6) and on 04/23/2025 between the hours of 9:21am – 9:38am, LPA interviewed Staff (7) regarding the allegation. On 06/18/2025, between the hours of 10:53am - 12:05pm, LPA interviewed Staff #8 (S8) - Staff #10 (S10) regarding the allegation.

3 out 10 staff interviewed confirmed an incident occurred between Resident #1 (R1) and Resident #2 (R2), but Staff had different various of the incident that occurred between R1 and R2.

7 out 10 staff interviewed had no knowledge of the incident that occurred between R1 and R2.

On 04/03/2025 between the hours 1:17pm - 2:26pm, LPA interviewed Resident #1(R1) – Resident #5 (R5).

On 04/03/2025 LPA attempted to interview Resident# 1 (R1) but due to the communication barriers, the resident was unable to answer interview questions.

On 04/03/2025 LPA attempted to interview Resident #2 (R2) who declined to be interviewed.

Report continues on LIC 9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250401131451

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: 06/18/2025

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

5 out of the 5 residents interviewed were unaware of the incident.

On 05/06/2025 between the hours of 2:30pm – 3:30pm, LPA conducted a records review for Resident #7 (R1) records and observed the following:

No history of aggravation per the resident’s physicians report (dated 09/29/2023) and need and service plan (dated 10/30/2024)

No history and or record of LIC 624: Unusual Incident/Injury Report (from December 2024 – April 2025)

On 06/18/2025, LPA returned to the facility and conducted a records review of the staff scheduled (December 2024) during the time of the incident. On the date of the incident 12/21/2024 at approximately 4:45pm, seven (7) staff worked between the hours of 8:45am - 6:12pm. On shift, there were a total of 6 Caregivers, 1 Medtech and Administrative Staff. During the time of the incident, the facility had a census of 61.

This incident is the first occurrence between R1 and R2. No similar incidents were reported for R1 and R2. The incident occurred suddenly which did not allow the staff to prevent the incident from occurring at the time

Based on the information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is unsubstantiated.

Exit interview conducted with Joel Niblett, Administrator Designee & copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3