197803745-6-9-2023-28-AS-MVAO-CTPR8N-20230713124813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 06/09/2023
Date Signed: 06/09/2023 03:24:38 PM

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
05/08/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230508132721

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: 59	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	12:21 PM
MET WITH:	Ana Y. Giron - Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff are not meeting resident’s modified dietary needs.
Staff do not ensure resident has access to personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with the Administrator, Ana Y. Giron and explained the reason for the visit.

During the initial visit on 5/16/2023, LPA Pena conducted a tour of the facility including R1's room and obtained copies of resident and staff rosters, R1's files such as: Physician's Report, Admissions Agreement, Face Sheet and list of Personal Property and Valuables. LPA interviewed Staff #1 (S1) and attempted to interview Staff #2 (S2) telephonically (at 11:55am), and left voicemail message requesting a call back.

During today's visit, the investigation consisted of the following: LPA Pena obtained copies of Resident & Staff Rosters, Regular/Diabetic Weekly Menu and Alternate Menu. LPA toured the kitchen and dining area once again and conducted interviews with Staff #2 (S2)-Staff #6 (S6), Resident #1 (R1) - Resident #7 (R7).
*****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
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-20230508132721

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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The investigation revealed the following:

Allegation: Staff are not meeting resident’s modified dietary needs. It is alleged that a resident has been prescribed a modified diet by a doctor but the facility does not give it to her. Interviews conducted with staff members revealed that the facility provides modified dietary meals and follow the residents' doctors instructions about dietary needs of the residents. S1 stated that they have a list of residents with modified diets and this information is provided to the kitchen staff. Interviews with kitchen staff indicate residents are receiving (3) meals a day based on the posted menu. Kitchen staff is aware of residents on modified diets and are providing the proper modified meals. Interviewed residents stated that the facility provides and meets residents modified dietary needs. Residents indicated that the facility posts regular and special diet/diabetic meal menu on the board daily. Residents have the option of choosing the alternate menu if they don't like the meal being served for that day. Residents also indicated that they receive (3) nutritious meals a day and of good portions. Interviewed residents indicated they do not have any concerns in regards to their diets. Some residents interviewed stated that they are not on a modified diet. LPA observed sufficient food supplies to meet the needs of residents. LPA also observed the board which posts the menu for the day (Breakfast/Lunch/Dinner) in the dining area . Review of the food menu indicate regular and diabetic meals are provided 3 times a day. LPA reviewed R1's file and physician's report and did not observe any special instructions or prescriptions for modified diet. Therefore there was insufficient evidence to corroborate with this allegation.

Allegation: Staff do not ensure resident has access to personal belongings. It is alleged that a resident's clothing was moved down to the basement and no longer has access to it. S1 denied the allegation and stated that residents have access to their personal belongings anytime, all they have to do is ask. Interviewed staff members indicated that any resident who asks a staff when they need to access their personal belongings in the basement will be assisted. Staff members indicated that residents are supervised when going to the basement due to safety reasons. Interviewed residents stated that they can access their belongings anytime if they need to. Residents indicated that they just asked the staff and/or went to the front desk to request access because they need to be supervised when going to the basement. Residents stated that they don't have any concerns with accessing their personal belongings. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, 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.

An exit interview was conducted, and a copy of this report was provided to the Administrator, Ana Y. Giron.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
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)

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