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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 06/02/2023
Date Signed: 06/02/2023 05:08:43 PM

Substantiated


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 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:
06/02/2023
UNANNOUNCEDTIME BEGAN:
03:51 PM
MET WITH:Administrator, Ana Y. GironTIME COMPLETED:
05:10 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) Bennette Pena conducted an initial 10-day complaint visit to investigate the above allegation. LPA met with Erika Becerra, Med-Tech and explained the purpose of the visit. Administrator Ana Giron arrived at 2:00pm and assisted LPA with the visit.

The investigation consisted of the following: LPA 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). ***CONTINUED ON LIC9099-C***

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
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: 06/02/2023
NARRATIVE
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Investigation revealed the following:

Allegation: Facility water is not within the required water temperature of 105 to 120 degrees Fahrenheit. It is alleged that the resident’s water temperature in the shower was checked and 3 hours later, it was cold, “it’s ice water”. Allegedly, on 5/30/2023, at 6:45am, a resident wanted to wash her legs, but the water was “ice cold”. Additionally, 2 weeks ago, when a resident was taking a shower, the water was hot then it turned cold. It is unsure if staff members are turning off hot water. Staff members interviewed stated that the hot water has been serviced to fix the hot water. Some staff members indicated that there was a power failure a few weeks ago and affected the hot water system in the facility. S1 stated that the facility's water heaters are on a timer. S1 indicated that someone was tampering the hot water system and an incident report was submitted to CCL on 6/2/2023. Interviews conducted with ten (10) residents indicated that there was no hot water for days about 2-3 weeks ago and they cannot take a shower or do their daily hygiene routine. Residents interviewed stated that sometimes the faucet and shower delivers hot water, sometimes not. LPA tested the water temperature in 12 random residents’ rooms and the temperature readings measured between 118.8 deg F- 124.4 deg F. which are not within the Title 22 Regs. required water temperature regulation. S2 assisted LPA while doing the water temperature check and confirmed LPA’s readings in multiple rooms (photos taken). Therefore, there is sufficient evidence to corroborate the allegation.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D and a civil penalty was assessed.

An exit interview was conducted, and a copy of this report was provided to the Administrator, Ana Giron along with the Appeals Rights.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2023
Section Cited
CCR
87303(e)(2)
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87303 Maintenance and Operation ..(e) Water supplies and plumbing fixtures shall be maintained...(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to ..... temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C
This requirement is not met as evidenced by:

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Administrator shall ensure the hot water temperature in all resident rooms meets Title 22 regulation. Administrator will submit a hot water reading for 7 days and contact the plumbing contractor to check the water heater, and submit proof of corrections by POC due date.
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Based on observation, the hot water temperature readings today measured between 118.8 deg F - 124.4 deg F which poses an immediate health and safety risk to residents in care.

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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
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