197803745-5-23-2023-28-AS-LHIS-CSBQ7P-20230530115527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:57:31 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
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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Facility water is not within the required water temperature of 105 to 120 degrees Fahrenheit.

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, plumber invoice 4/2/2023, on-call cook/S4 file, and special diet listt were obtained.

***Investigation narrative continues next page.

Substantiated

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: Facility water is not within the required water temperature of 105 to 120 degrees Fahrenheit. It is alleged that the faucets in resident rooms are not delivering hot water during early morning and late at night. In addition, on May 19, 2023, a resident attempted to take a shower at approximately 12:30 pm, but the room did not have any hot water; between 12:30 pm - 3:45 pm. In addition, another resident got in the shower at 7:00 pm on May 20, 2023, and only had 5 minutes of hot water and had to rinse off the soap with "ice cold" water. A total of 12 residents were interviewed, all 12 residents stated the faucets are not delivering hot water during early morning hours, until approximately 8:30 am - 9:00 am, that is infringing on their early morning hygiene schedule. A total of seven (7) staff were interviewed; of which three (3) confirmed residents have told them room faucets are not delivering hot water early in the morning or late at night.

During the physical plant inspection, LPA tested the water temperature in 12 resident rooms and kitchen. The water boilers in the basement floor were inspected. The facility has 4 energy efficient tankless water heaters and 2 commercial water heaters. The tankless/electronic water heaters are set for 122 Degrees Fahrenheit. Per Administrator, the tankless water heaters are on a timer. Today's water temperature readings measured between 113.5 DF - 126.9 DF (pictures were taken); not within required water temperature regulation. Therefore, there is sufficient evidence to corroborate the allegation.

Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D.

Exit interview was conducted with Administrator Ana Giron. A copy of the report and appeal rights were issued.

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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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/24/2023 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water	1 2 3 4 5 6 7	Administrator shall ensure the hot water temperature in all resident rooms meets Title 22 regulation at all times of the day. Facility has tankless water heaters that are on a timer. Have the plumbing contractor check the water heater, and submit proof of corrections by tomorrow.
	8 9 10 11 12 13 14	used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Based on observation, the hot water temperature readings today measured between 113.5 DF - 126.9 DF; which poses an immediate health and safety 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) 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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