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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 06/09/2023
Date Signed: 06/09/2023 11:43:54 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
06/08/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230608142917
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: 62DATE:
06/09/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Ana Jiron - AdministratorTIME COMPLETED:
11:58 AM
ALLEGATION(S):
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Staff yelled at resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met Ana Jiron (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora obtained copies of the resident and staff rosters, incident report dated 06/08/2023, and interviewed Administrator, Staff 1 - Staff 4 (S1 - S4), and Resident 1 - Resident 7 (R1 - R7).

The investigation revealed the following: regarding the allegation "staff yelled at resident in care", it is alleged that a resident asked for help and the staff yelled at the resident. Staff interviewed denied the allegation. S4 witnessed this incident and stated that S1 was not yelling and that it was actually the resident the one yelling. Residents interviewed revealed that 5 out of 7 residents could not corroborate the allegation. R7 witnessed this incident and stated that S1 was respectful and the resident was the one being verbally aggresive. (Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
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-20230608142917
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: 06/09/2023
NARRATIVE
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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.

Exit interview held and a copy of the report was provided
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2