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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803745
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:56:51 PM


Document Has Been Signed on 05/23/2023 04:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 DOWNEYFACILITY NUMBER:
197803745
ADMINISTRATOR:ANA YESENIA GIRONFACILITY TYPE:
740
ADDRESS:11111 MYRTLE ST.TELEPHONE:
(562) 869-2401
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:150CENSUS: 63DATE:
05/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Ana Giron, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Galarza generated this Case Management - Other report in conjunction with complaint control # 28-AS-20230515134232 pertaining to observations made during the investigation. The purpose of the report was explained to Administrator Ana Giron.

Cook/Staff (S1) is not cleared or associated to the facility. The staff has been working at the facility for several months. Per Administrator, the staff was hired through an agency. Administrator obtained the staff file from the corporate office. Staff (S1) is cleared through Clear Checks- National Background Check.

Since staff (S1) works at the facility on a regular basis, the facility was advised to obtain a Criminal Background clearance and associate the staff to the facility.


An exit interview was conducted and a copy of the report was issued to Administrator Ana Giron.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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