197803745-6-19-2023-28-AS-RORN-CTVTJP-20230719144642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 06/19/2023
Date Signed: 06/19/2023 04:48:42 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
05/30/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230530111256

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: 61	DATE:	06/19/2023
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Ana Y. Giron-Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff not treating resident with respect.
Staff not providing adequate food service.

INVESTIGATION FINDINGS:

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

On 6/02/2023, LPA Pena conducted the initial complaint visit and obtained copies of Resident & Staff Rosters, 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. LPA toured the facility’s common areas focusing on the kitchen, dining area and water temperature checks. An inspection of the kitchen, food supply/storage, dining area, food served during lunch and water temperature check on random residents’ rooms in the 1st and 2nd floors (Rooms: #3, #15, #18, #26, #27, #37, #38, #40, #52, #56, #57, #83) was conducted. LPA reviewed the files of Resident #1 (R1) and obtained copies of the following documents: Identification and Emergency Information Sheets, Appraisal Needs and Services Plan, and Physician's Reports. LPA also reviewed the files of Staff #3 (S3) and obtained copies of the following documents: Personnel report and training certificate for food handling and safety issued on 5/18/2023. LPA interviewed Staff #1 (S1) – Staff #6 (S6) and Resident #1 (R1) – Resident #10 (R10).

During today's visit, LPA Pena obtained the Staff & Resident Rosters, 8 weekly sample food menu, dietician information, special diet list. LPA conducted a physical plant tour of the facility once again focusing on the kitchen, food supplies and dining area. LPA observed the daily food menu posted (photo available) on the board outside the dining area.
*****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: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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-20230530111256

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: 06/19/2023

NARRATIVE

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Allegation: Staff not treating resident with respect. It is alleged that a staff was being rude towards a resident. Interviews conducted with staff members indicated that none of the staff was being rude to any residents. Staff members stated that some of the residents were the ones being rude to the staff. Staff members also indicated that they receive training about the residents rights and they treat them with respect and do not yell, threaten or interrupt the residents. S5 denied the allegation and stated that she never interrupted any resident and was not aware of the incident. Interview conducted with the residents indicated that they were not aware of the incident and did not hear a staff being rude towards a resident. Residents indicated that none of the staff were rude to them. Therefore, there was insufficient evidence to corroborate with this allegation.

Allegation: Staff not providing adequate food service. It is alleged that the staff is providing residents with “crappy food”. It is also alleged that the “food isn’t getting any better”, that tuna salad had “no flavor” and food being cold. Interviews conducted with staff members, including S1 revealed that they offer food based on the dietician recommendation. Staff members indicated that they offer alternate menu to the residents consisting of sandwich, Chef's salad and fruit plate. Staff members also indicated that they offer different food options. (8) out of (10) resident interviewed indicated that the food service is okay, and they are satisfied. Residents indicated that they can order from the alternate menu if they do not like the meal offered on that day, although it would be nice if they see more of a variety of food. (2) out of (10) residents stated that food is not up to par. For example, they get bread that is hard as a brick mainly on dinners and breakfast and the food options are the same for many years. LPA observed the kitchen, cooked meals, food supplies/storage, dining service, as well as the food served during lunch. On 6/02/2023, LPA observed that there were (2) staff preparing and serving meals. The lunch offered were cheese quesadilla, green salad, rice and beef noodle soup. Alternate menu offered were peanut butter and jelly sandwich, mixed green salad and fruit plate. The food items were served as required. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of facility file records and LPA's observations, 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.

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

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC9099 (FAS) - (06/04)

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