197803745-11-10-2021-28-AS-LHIS-C93LD7-20211124073929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 11/05/2021
Date Signed: 11/10/2021 02:33:39 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
05/06/2021 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210506114926

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: 74	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Victor Ortiz		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff are not meeting residents needs.
Staff don't treat resident with respect.
Resident denied phone calls.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced Subsequent visit and met with Med Tech Victor Ortiz to discuss the purpose for todays visit.

Investigation consisted of the following: On 05/13/21 LPA Wesley requested a copy of the staff and resident roster, toured the facility, interviewed staff, and interviewed residents.

Regarding allegation: Staff are not meeting residents needs. LPA Wesley interviewed a random selection of residents who advised that their needs are being met. Residents said they receive 3 meals per day, medication, rooms are cleaned, linen is changed about once or week or when needed, assistance with grooming and showering. Staff were interviewed and advised that they meet all of the residents needs, they clean the residents room, do their laundry, provide assistance with elements of daily living(ADLs) if they need help. Residents said they have no complaints, the food is okay, the services are good, and staff assist them in a
Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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 28-AS-20210506114926

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: 11/05/2021

NARRATIVE

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timely manner. Administrator Giron said that the caregivers and housekeepers provide the residents assistance on a daily basis, and she has not received any complaints from residents or their loved ones that the staff were not meeting the residents needs. During the investigation it was not specified what type of needs the staff weren't meeting and the name of the staff who did not meet resident #1(R1's) needs. LPA Wesley was not able to interview resident #1 as they no longer reside in the facility and their whereabouts are unknown. There is not sufficient information/evidence to support the allegation: Staff are not meeting residents needs.

Regarding allegation: Staff don't treat resident with respect. LPA interviewed staff(S1-S4) who said they have always treated the residents with dignity and respect, and has never witnessed any staff mistreat any of the residents talk down to them, act rude or mean to the residents. LPA Wesley Interviewed Administrator Ana Giron who advised that she has never witnessed or received any complaints from residents, that staff has mistreated them and has not treated with dignity or respect. Administrator also said that she hasn't received any complaints from staff, or the resident's loved ones that staff were rude, mean and talked down to the residents. During the interviews with a random selection of residents, LPA Wesley was informed by the residents that they do not have problems with the staff and none of the staff have mistreated them, acted disrespectful or talked down to them. Residents stated that the staff are nice and treat them with dignity and respect. LPA Wesley was not able to interview resident #1 as they no longer reside in the facility and their whereabouts are unknown. There is no sufficient evidence to support the allegation: Staff don't treat resident with respect.

Regarding allegation: Resident denied phone calls. LPA Wesley interviewed Administrator Ana Giron who said the residents are not denied phone calls, Administrator advised that most residents have their own cellphones, but there are phones located in the facility hall ways, there is a public phone, and the she also made calls for the residents. Administrator said that R1 had their own phone and never requested to use the facility phone. Administrator also said R1's loved ones were always in communication with them as they were responsible for transporting R1 to their medical appointments and other locations. A random selection of residents were

Continued on LIC 9099C(Page 3).

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210506114926

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: 11/05/2021

NARRATIVE

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LIC 9099C Page 3.

interviewed and said they were never denied phone calls, and said the facility has tablets so they can see their family because no one can come into the facility because of the COVID 19 restrictions. LPA Wesley was not able to interview resident #1 as they no longer reside in the facility and their whereabouts are unknown. There is no sufficient evidence to support the allegation:

Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

There were no deficiencies cited. A copy of the report was given during the exit interview.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3