197803745-12-1-2025-28-AS-DSIS-DP6Q95-20251208105746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 12/01/2025
Date Signed: 12/01/2025 11:34:34 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/19/2025 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251119092122

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: 86	DATE:	12/01/2025
		UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Erika Becerra		TIME COMPLETED:	11:53 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not maintain a comfortable temperature for a resident in care.
Staff did not ensure resident's room was not in disrepair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with MedTech/Assistant Administrator Erika Becerra and explained the purpose of today's visit.

The investigation consisted of the following:
On 11/25/25 LPA obtained copies of staff & resident rosters, tour of facility, LPA tested temperature and electrical outlets throughout facility during tour. Interviews with 3 Staff (S1-S3) and 9 Residents (R1-R9) were conducted.
During todays visit 12/1/25 LPA delivered findings on the above allegations.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025

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 2

Control Number 28-AS-20251119092122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY INN OF DOWNEY	FACILITY NUMBER: 197803745
	VISIT DATE: 12/01/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Investigation revealed the following:
Allegation: Staff did not maintain a comfortable temperature for a resident in care.
It is alleged that the facility is without heat and the vents are blowing out cold air only. LPA toured facility a total of 9 resident rooms were toured, LPA observed vents in rooms were operable and blowing cool air, temperatures were tested in each room and measured within a comfortable temperatures that read between 71-80 degrees F. Rooms were also observed to have portable heaters and administrator confirmed that if a resident requests for a personal heater one will be provided to them. LPA also checked thermostats throughout the facility (total of 4) and each were within the appropriate range and measured between 72-75 degrees F. LPA interviews 3 staff and each denied the allegation and stated that if residents express that they are cold they are provided with either a portable heater or additional blankets. LPA interviewed 9 residents and 8 out of 9 residents denied the allegation and stated that although it may get cold at night they are provided with the portable heater and extra blankets if needed and have no issues with the temperature being uncomfortable.

Allegation: Staff did not ensure resident's room was not in disrepair.

It is alleged that there is an electrical problem at the facility and the electricity shuts down when more than one thing is plugged in. LPA toured facility and tested outlets in 9 resident bedrooms and each outlet was operable. LPA interviewed 3 staff and each denied the allegation. Interview with Administrator revealed that R1 often times has multiple items plugged in on different power strips and will sometimes cause a short in the circuit, Staff will go to circuit breaker once they are made aware and will reset the circuit breaker and power will be operable in R1’s room. During tour LPA inspected R1’s room and observed multiple devices plugged in to power strips and did not observe any of the outlets being inoperable. LPA interviewed 9 residents and 7 out of 9 residents denied the allegations and stated that they do not have any issues with the electricity in their rooms or throughout the facility.

Based on statements and interviews conducted with staff/residents, tour of facility and LPA's observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2