197803745-4-20-2023-28-AS-LHIS-CRBMU5-20230428095434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 04/20/2023
Date Signed: 04/20/2023 03:04:49 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
04/14/2023 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20230414114412

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: 64	DATE:	04/20/2023
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Administrator Ana Giron		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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On 04/20/23 at 08:40 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Ana Giron (Administrator) and explained the purpose of the visit.

Prior to the visit LPA reviewed a copy of the eviction noticed dated April 13, 2023, for Resident #1 and Resident #2. LPA also received an Unusual Incident Report describing a physical altercation between Resident #1 and Resident #2 dated 4/9/2023 with the eviction notice. The Residents received a copy of the notice April 13, 2023.

During today’s visit LPA obtained resident/ staff roster, admissions agreement for R1 and R2, House Rules for R1 and R2 and reviewed the camera and observed R1 and R2 physical altercation. 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 6 residents who shall be referred to as: R1 through R6. 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: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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-20230414114412

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: 04/20/2023

NARRATIVE

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The investigation reveals the following: Regarding "Illegal Eviction", it is alleged that the facility want to evict resident R1, if they do not enroll in the Assisted Living Waiver program. The administrator denied evicting residents who are not on the assisted waiver program and confirmed the two recent evictions are based on breaking house rules. S1 stated they were present during the altercation but did not see which resident started the altercation. S1 and S2 both stated that they heard R1 asking someone on the phone to bring a gun to the facility and they contacted police. R1 confirmed punching R2 first due to R2 acting aggressively but denied mentioning a gun during the altercation. R1 also stated R2 had made threats before but they never reported those incidents to staff. R2 denied receiving an eviction notice and stated R1 started the physical altercation. R3 through R5 stated they were not witnesses to the start of the altercation and arrived at the end. R6 stated R2 started the physical altercation by hitting R1 first. LPA reviewed the cameras and observed R1 hitting R2 when R2 raised up from wheelchair. The house rules state the following” All residents will treat other residents and staff with respect free from verbal or physical abuse of any kind and free of coercion and intimidation. Therefore, physically, and verbally abusive behavior or intimidation with physical and verbal threats will not be tolerated. LPA observed the reason for the eviction is due to aggressive and physical behavior towards residents and verbally abusing staff and other residents. Although the reasons maybe valid but the eviction notice does not meet SB 781 and the health and safety code 1569.683. The eviction notice failed to indicate resources available to assist the residents in identifying alternative housing and care options, including public and private referral services and case management organizations.

Based on LPA's observation, interviews, and file review the investigation revealed: Although the allegation may have happened or is valid, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated.

Exit interview conducted with Ana Giron and a copy of this record and appeals rights provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230414114412

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: 04/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/21/2023 Section Cited HSC 1569.683(a)(2)	1 2 3 4 5 6 7	HSC 1569.683 (a)(2) ... a licensee of a residential care facility for the elderly who sends notice of eviction to a resident ... notice to quit shall include all of the following: (2) Resources available to assist in identifying alternative housing and care options including public and private referral services and case management organization.	1 2 3 4 5 6 7	The administrator shall submit a new eviction notice to CCL prior to issuing the notice to residents and get LPA approval. The notices shall include all information required by HSC 1569.683 by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: LPA reviewed the eviction notices and observed missing information required by health and saftey code 1569.683, which poses an immediate health and safety, or personal rights risk to persons in care.	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: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

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