197803745-12-22-2022-28-AS-MVAO-CPHTUC-20230301140207

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 12/22/2022
Date Signed: 12/22/2022 12:10:54 PM

Substantiated

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
12/16/2022 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20221216092728

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: 67	DATE:	12/22/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ana Giron Administrator		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Facility staff allow residents to smoke in non-smoking areas

INVESTIGATION FINDINGS:

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On 12/22/22 at 9:00 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with (S1) and explained the purpose of the visit. Administrator Ana Giron arrived at 10:30 and joined the visit.

During today’s visit LPA toured the facility with S1. LPA obtained resident/ staff roster, House rules and pictures of the front patio. LPA also interviewed: Administrator and a total of two (2) staff who shall be referred to as S1, and S2. LPA interviewed a total of 7 residents who shall be referred to as: R1 through R7.
Report continued 9099c

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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-20221216092728

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: 12/22/2022

NARRATIVE

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The investigation reveals the following: Regarding "Facility staff allow residents to smoke in non-smoking areas", it is alleged that the residents are being allowed to smoke in the non-smoking areas. During the visit LPA toured the facility and did not observe residents smoking in the nonsmoking areas. LPA also observed there are 2 sides to the front porch and cigarette buds were seen in plants on both sides of the front porch. The Administrator stated they allow the residents to smoke on front porch but only on the side without the nonsmoking signs and the facility also cover the nonsmoking signs. 2/2 staff interviews confirmed residents can smoke on front porch only during rainy days. 5/7 residents stated the facility allows residents to smoke on the front porch. 1/7 residents stated they have no knowledge of the allegation. 1/7 residents denied the allegation. Per plan of operation: house rules “Residents agrees to refrain from smoking any form of tobacco or other legal substance except in the facility’s designated smoking areas”. During the visit Administrator showed LPA a canopy bought for the other side of the front porch.

Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22 are being cited on the attached LIC 9099D.

Exit interview was conducted with Ana Giron administrator and a copy of this report LIC 9099D, and appeal rights was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221216092728

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/22/2023 Section Cited CCR 87208(a)	1 2 3 4 5 6 7	87208(a). Plan of Operation. Each facility shall have and maintain a current, written definitive plan of operation...... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will subitt a written plan or update to the plan of operation, House rules and Admissions agreement detailing the designated smoking areas by POC due date.
	8 9 10 11 12 13 14	Based on physical plant inspection LPA observed nonsmoking sign on the front porch and cigarette buds on the front porch. Based on interviews 5/7 residents confirmed staff allowed them to smoke on front porch which is a nonsmoking area. 2/2 staff stated residents are only allowed to smoke on the front porch on rainy days. Per plan of operation: House rules residents are not allowed to smoke in nonsmoking areas.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

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