197803745-9-12-2023-28-AS-RORN-CVTSSJ-20230919140757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 09/12/2023
Date Signed: 09/12/2023 02:01:41 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
05/03/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230503152642

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: 62	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Patricia Hernandez - Receptionist		TIME COMPLETED:	11:44 AM

ALLEGATION(S):

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Staff yells at resident in care.
Staff spoke inappropriately to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to investigate the allegations listed above and deliver findings. LPA met with Patricia Hernandez, Receptionist and explained the reason for the visit. Administrator Ana Giron was out of the facility and instructed Patricia to assist LPA with the investigation on her behalf.

During the initial visit on 5/05/2023, LPA Pena toured the common areas and obtained copies of the following: Resident & Staff Rosters, House Rules, Daily Meal Menu, Resident #1 (R1) - Resident #2 (R2) files such as: Admission's Agreement, Physician's Report, Identification and Emergency Information Sheet, Preplacement Appraisal and Appraisal and Personal Rights. LPA also interviewed Staff #1 (S1)- Staff #3 (S3). Copies of the photos taken to be emailed to LPA.

During the visit on 8/29/2023, the investigation consisted of the following: LPA obtained copies of the following: Resident & Staff Rosters, In service training for Residents rights and toured the common areas. LPA also interviewed Staff #4 (S4) - Staff #6 (S6) and Resident #1 (R1) - Resident #10 (R10).

During today's visit, the investigation consisted of the following: LPA obtained copies of the Resident & Staff Rosters and toured the common areas. ***CONTINUED ON LIC 9099-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: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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-20230503152642

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: 09/12/2023

NARRATIVE

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Allegation: Staff yells at resident in care.

In regards to the allegation “Staff yells at resident in care”, it is alleged that staff members came into the resident’s room and yelled at her when it’s time to empty her urinary catheter bag.” Interviews conducted with 6 out of 6 staff members all denied the allegation. Staff indicated they did not yell or witnessed a staff yelled at R1. Staff also indicated they are trained in mandated reporting, resident rights and zero tolerance. Staff stated that they do not clean or empty R1's catheter bag because R1 is self-responsible and has a home health nurse who assists with her catheter. 9 out of 10 residents all denied the allegation and stated that staff never yelled at them, nor they have witnessed staff yelling at R1 or other residents. During the visit, LPA observed staff interacting with residents in appropriate manner. Therefore, there was insufficient evidence to corroborate with this allegation.

Allegation: Staff spoke inappropriately to resident in care.

In regards to the allegation “Staff spoke inappropriately to resident in care”, it is alleged that when R1 asked for secondary lunch option, a staff made a snide comment that was disrespectful and rude.” Interviews conducted with 6 out of 6 staff members all denied the allegation. None of the staff interviewed recall such an incident and stated that they will never deny any resident of their meal request. Staff indicated they would never speak inappropriately to residents in care. Staff also indicated they are trained in mandated reporting, resident rights and zero tolerance. 9 out of 10 residents all denied the allegation and stated that staff never spoke inappropriately to them, nor they have witnessed staff doing that to R1 or other residents. During the visit, LPA observed staff speaking appropriately to residents and did not observe anything that would raise a concern. 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.

With the facility Administrator, Ana Y. Giron's consent, exit interview was held and a copy of this report was provided to the Receptionist, Patricia Hernandez who also signed this report.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

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