197803745-7-1-2020-28-AS-FFIS-BS9P5E-20200807110034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 07/01/2020
Date Signed: 07/01/2020 03:56:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2020 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200625125651

FACILITY NAME:	COUNTRY INN OF DOWNEY		FACILITY NUMBER:	197803745
ADMINISTRATOR:	ANA YESENIA GIRON		FACILITY TYPE:	740
ADDRESS:	11111 MYRTLE ST.		TELEPHONE:	(562) 869-2401
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	150	CENSUS: 89	DATE:	07/01/2020
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Darkis Giron (Assistant Administrator)		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility failed to prevent dementia resident from AWOLing.
Facility failed to make family aware of resident AWOLing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today's complaint investigation was conducted telephonically with Darkis Giron (Assistant Administrator)

During today's investigation, LPA interviewed the Assistant Administrator, Staff #2 and Resident #1, obtained a copy of R#1's Physician report, Incident reports, Missing Resident Procedures and Staff/Resident roster.

In regards to the allegation: Facility failed to prevent dementia resident from AWOLing. A review of the Physician report indicate that Resident #1 is not diagnosed with dementia and is able to leave the facility unassisted. Interviews with Staff and Resident revealed that Resident #1 informed Staff prior to leaving the facility. There is no evidence that Resident was absent without official leave (AWOL). Continue to LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200625125651

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY INN OF DOWNEY	FACILITY NUMBER: 197803745
	VISIT DATE: 07/01/2020

NARRATIVE

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In regards to the allegation: Facility failed to make family aware of resident AWOLing. Investigation revealed that Resident #1 left the facility on 06/25/20 and informed Staff #2 and #3 that Resident #1 was headed to see the doctor, however, Resident #1 did not return to the facility at 8 am. Staff reported Resident #1's AWOL and informed local law enforcement. Family was made aware on 06/25/20 at 8 am of Resident #1 not returning from seeing the doctor. Therefore, Resident #1 family was notified of Resident #1's AWOL in a timely manner.
Based on LPA's interviews and record review, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

A telephonic exit interview was conducted with Darkis Giron (Assistant Administrator) and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2020

LIC9099 (FAS) - (06/04)

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