197803745-5-23-2023-28-AS-LHIS-CSBQ7Q-20230530115529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:59:29 PM

Unsubstantiated

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
05/15/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230515134232

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: 63	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Ana Giron, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff not providing adequate food service.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegations. The purpose of the visit was explained to Med-Tech Erika Becerra. Administrator Ana Giron arrived towards the end of the visit.

The investigation consisted of the following: A physical plant tour of the facility with a focus on water temperature/ plumbing operation and food service was conducted. An inspection of the kitchen food supply, cooked meals, and dining service was observed. Staff (S1-S7) and residents (R1- R12) were interviewed. Water temperature was tested in a total of 12 resident rooms [4,12, 15, 23, 33, 34, 37, 40, 43, 44, 57, 66]. Copies of resident roster, LIC 500 Personnel Report, 8 weekly sample food menu, dietician information, on-call cook/staff 4 file, plumber invoice 4/2/2023, and special diet list were obtained.

***Investigation narrative continues next page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230515134232

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: 05/23/2023

NARRATIVE

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Allegation: Staff not providing adequate food service. It is alleged that during the last six (6) months the food is often served cold, and that the facility does not serve a variety of meals. For example, beef stew is cooked and again given to residents 2 days later. Eight (8) out 12 residents interviewed stated the food is often served cold, especially during the second dining seating. The majority of the residents also stated that the facility does not serve a variety of meals i.e. beef stew is served twice a week. Three (3) out of seven (7) staff stated that food menu items are repeated at least twice a week, but all staff stated the food is not served cold. Lunch dining service and kitchen operations were observed, special diets were reviewed, and kitchen food supply was inspected. During today's visit, 2 kitchen staff were observed, an agency staff (S4) cook and a dishwasher. The lunch meal consisted of baked chicken, green salad, French fries, and soup. The food items were served as required. Facility's menus were reviewed, they consisted of a variety of foods for each meal. There is insufficient evidence to corroborate the allegation.

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

No Deficiencies cited under California Code of Regulations Title 22

Exit interview was conducted with Administrator Ana Giron. A copy of the report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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