197803745-4-17-2023-28-AS-LHIS-CTGKDG-20230706074840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 04/17/2023
Date Signed: 04/17/2023 02:16:49 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
04/10/2023 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20230410110435

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: 64	DATE:	04/17/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Anna giron		TIME COMPLETED:	02:31 PM

ALLEGATION(S):

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Administrator does not ensure a safe and healthful environment by threatening a resident in care

INVESTIGATION FINDINGS:

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On 04/17/23 at 11:00 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Ana Giron (Administrator) and explained the purpose of the visit.

During today’s visit LPA and Staff S1 toured the facility. LPA obtained resident/ staff roster. LPA also interviewed: Administrator and a total of two (2) staff who shall be referred to as S1, and S2. LPA interviewed a total of 7 residents who shall be referred to as: R1 through R7.

Report continued 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

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-20230410110435

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: 04/17/2023

NARRATIVE

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The investigation reveals the following: Regarding "Administrator does not ensure a safe and healthful environment by threatening a resident in care", it is alleged that the facility threaten to evict the resident if they did not get their brief changed. The administrator denied the allegation stating they have not threatened any of the residents. If a resident refused to be changed staff would return later. 2/2 staff denied the allegation. 6/7 residents denied the allegation stating that staff has never threaten them or other residents. 1/7 residents confirmed the allegation stating staff repeatedly violated their personal rights by forcing them to eat, receive medical care and denying their choice of when to get their brief changed.

Based on LPA's observation, interviews, and file review the investigation revealed: 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 allegations are UNSUBSTANTIATED.

Exit interview conducted with Ana Giron and a copy of this record provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023

LIC9099 (FAS) - (06/04)

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