Brittany House

87466 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: 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 posed a potential risk to the health, safety and personal rights of the resident in care.

87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee failed to ensure a sufficient number of competent staff to meet R1’s needs. R1’s foot was swollen for several weeks, no one followed up with hospital visits, and ultimately R1’s toe became infected and had to be amputated. This poses a potential health risk to residents in care.

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.

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.

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. Based on interview, observation & record review Staff 11 (S11) did not have any documented medication administration training on file but was administering medication to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Observation of the Resident: The licensee shall ensure residents are regularly observed for changes in physical, mental, emotional, and social functioning, and appropriate assistance is provided when observations reveal unmet needs. This requirement was not met as evidenced by: Based on interviews and records review, facility staff observed Resident 9 (R9) in distress & the facility did not provide timely medical attention. Narcan was administered without a prescription from R9's primary care doctor, posing an immediate health and safety risk to persons in care.

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observation and interview, staff failed to answer the call light in a timely manner. On 01/21/2026, LPA conducted a call light test observed staff not responding. This violation poses a potential health, safety, and personal rights risk to residents in care.

(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) orThis 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.

Reporting Requirements: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)...This requirement was not met as evidence by: Based on records review, the department did not receive a LIC 624 regarding R9 being administered a controlled medication dosage nor proof of medical attention being provided on 10/30/2025 or 10/31/2025. This violation poses a potential health, safety, and personal rights risk to residents in care.

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.

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.

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.

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.

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.

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.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D)...This requirement was not met as evidence by: Based on observation and record review, facility staff failed to ensure to report to (R#1)'s responsible party regarding (R#2)'s health condition.This poses a potential health and safety risk to residents in care.

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.

Allowable Health Conditions and the Use of Home Health Agencies(b)Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (2) The licensee provides the supporting care & supervision needed to meet the needs of the resident receiving home health care. Based on interviews and record review, the facility did not have a restricted health care plan for the cholecystostomy tube, and staff were not informed of the type of tube inserted or the required care & supervision need.

Admission Agreements...(B)Rate for additional items and services, including: (1) A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. Based on record review and interviews, the licensee did not ensure R1 admission agreement contained a comprehensive description of additional fees or the fee schedule for services not included in the basis services.

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

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: 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.

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training &/or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help.

87463 Reappraisals: The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition.... based on records review and interviews LPA did not observe a re-aappraisal on file for when R11 returned to the facility nor a care plan for catheter which poses a potential health and safety risk to residents in care.

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.

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on observation and interviews the licensee did not comply with the section cited above by R1 not being accorded a safe environment by not having access to their equipment such as their call button which posed a potential health, safety or personal rights risk to person in care.

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

87463 Reappraisals :The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition.... based on records review and interviews LPA did not observe a re-assessmnet on file for when R11 returned to the facility which poses a potential health and safety risk to residents in care.

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.

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 occurrence 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

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training &/or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help. This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospital

87224 Eviction Procedures(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)...This requirement was not met as evidence by: Based on interviews with (S#1), the facility failed to ensure that resident (R#1) was properly assessed prior to hospital discharge. (S#1) informed the hospital social worker that (R#1) required more assistance than the facility could provide, which resulted in (R#1) not being able to return to the facility upon discharge. This poses a potential health and safety risk to the residents in care.

Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidence by: Based on records and interviews conducted the licensee failed to ensure that 911 was called after R1’s unwitnessed fall on 11/14/2024, which posed an immediate health, safety and personal rights risk to residents in care.

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on record reviews and interviews conducted the licensee failed to ensure that supervision was provided to meet the residents’ needs. On 01/14/2025 staff S1 and S2 left R1 unsupervised which resulted to R1 falling and sustaining a fracture which posed an immediate health, safety and personal rights risk to residents in care.

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and the appropriate assistance is provided when such observations\ reveals unmet needs…This requirement was not met as evidence by: Based on observation and interviews, staff did change resident, however due to the frequency of the urination, the resident continued to be in soiled clothing for a period of time due to the resident urinating on themselves and in their bed. This violation poses a potential health and safety or personal rights risk to residents in care.

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation, the resident’s bedroom #207 has a strong odor of urine and the carpet was observed to have liquid stains, possibly urine stains based on the odor emanating from the carpeting. This violation poses a potential health and safety or personal rights risk to residents in care.

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.

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.

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.

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.

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

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...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: Based on observations and a review of records, the licensee failed to comply with the aforementioned section. The LPA observed inconsistencies and gaps in the medication administration records, which posed a potential risk to the health, safety, or personal rights of the individuals in care.

87412 personnel recordsLicensees shall maintain in the personnel records verification of required staff training and orientation. The following staff training and orientation shall be documented: For staff who assist with personal activities of daily living.... Based on interviews and record reviews, the licensee and Administrator did not comply with the section cited above as there was no documentation confirming Staff 5-7 have obtained and passed required training(s).

87465 Incidental Medical and Dental CareThe following requirements shall apply to medications which are centrally stored:The licensee shall be responsible for assuring that a record of centrally stored prescription medications....The name of the resident for whom.... Based on interviews and record reviews, the licensee and Administrator did not comply with the section cited above as medications passes were not properly documeted which is a potential a potentila health and safety risk for residents in care.

87221 Resident CouncilsThe facility shall permit the formation of a resident council by interested residents, provide space and post notice for meetings, and provide assistance in attending meetings for those residents who request it. In order to permit a free exchange of ideas, at least part of each meeting shall be allowed to be conducted without the presence of any facility personnel. Residents shall be encouraged, but shall not be compelled to attend. The purpose of such an organization shall be to work with the administration in improving the quality of life for all residents by enriching the activity program and to discuss the services offered by the facility and make recommendations regarding identified problems.This requirement was not met as evidenced by: Based on interviews and record reviews, facility staff did not assist residents in the formation of a resident council. This poses a possible personal rights violation to all residents in care.

87465(a)(4) Incidental Medical and Dental CareA 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: Based on observation and record review, the licensee did not comply with the section cited above as during medication reviews, LPA observed discrepancies in all 5 residents medication administration records which poses/posed a potential health, safety or personal rights risk to persons in care.

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.

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.

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..

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.

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 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.

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 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 an incident with (R1) change in condition and hospitalization on 08/05/24. 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.

87705 Care of Persons with Dementia(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia…(1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator…when a resident’s behavior or condition changes. This requirement is 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 notify the responsible person/conservator for (R1) when (R1) was hospitalized on 08/05/24. This violation poses a potential health, safety, or personal rights risk to persons in care.

87217 Safeguards for Resident Cash, Personal Property, and Valuables(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources.This requirement is not as evidenced by: Based on document review and interviews, facility staff did not take appropriate measures to safeguard residents belongings. This poses a potential personal rights risk to persons in care.

87468.1(a)(8) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations...This requirement is not met as evidence by: Based on interviews conducted and records reviewed the administrator failed to inform the responsible parties about the construction of the facility and movement of the residents. Which poses a potential health risk to residents in care.

87468.1(a)(2) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on interviews conducted, the administrator failed to ensure a resident's personal rights due to the facility not letting them know that they would be relocated to a different unit in the building, causing confusion and feeling unsafe in the facility, which posed a potential health risk to residents in care.

87465(a)(2) 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: The licensee shall provide assistance in meeting necessary medical and dental needs…This was not met as evidence by based on records reviewed and interviews, med tech admitted to LPA that he was notifying the nurse about refilling medications last minute and that would cause a delay, where resident would go days without medication.

87464(f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.This was not met as evidence by based on records reviewed and interviews, med tech failed to give medication to resident which poses a potential health, safety risk to persons in care.

87204Limitations-Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum numbe of persons who my receive sedrvice at any one time. An exceptio my be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity,This regeulation was not met based on: Interviews and file review, C1 has paid to come and stay at the faclitily during the day, meals and services are porvided.

87615 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 ve admitted or retained in a residental care faclity for the elderly: (4) Staphylococcus aureus ("staph") infection or other serious infection.This regulation was not met based on evidence by:Record review and interviews, the licensee failed to ensure resident R1 did not have a phohibited health condition