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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 12/01/2021
Date Signed: 12/01/2021 11:13:10 AM



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
01/02/2020 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200102164741
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: 74DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erika Becerra, Med-TechTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Unlawful eviction.
Staff failed to safeguard residents belongings.
Resident not awarded privacy.
Staff sent resident to hospital under false pretenses.
Staff did not provide a safe environment for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The purpose of the visit was discussed with Med-Tech Erika Becerra.

The investigation consisted of the following: On 1/19/2020, at 10:25 AM & 11:10 Am a tour of the facility main floor exits was conducted. The north side door was observed to be open due to sidewalk construction around the perimeter of the facility and front entrance. The south side emergency exit door located next to the kitchen was opened and unable to close without force. Staff (S1-S3), and residents (R1- R9) were interviewed. Former resident (R10's) file documents [Contact information, physician report, resident appraisal Appraisal/Needs and Services Plan, admission agreement, psychiatric evaluation, six (6) incident reports, Client/Resident Personal Property and Valuables, and 30-Day Eviction Notice issued on 8/28/2019 ] were reviewed and obtained. During today's visit, resident (R11) was interviewed, and a physical plant tour of the 1st floor exit doors was conducted.

See LIC 9099C for continuation of report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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 4
Control Number 28-AS-20200102164741
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: 12/01/2021
NARRATIVE
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Allegation: "Unlawful eviction." Based on interviews conducted and record review the findings indicate the 30-Day Notice to Vacate The Facility" that was issued on 8/28/2019 to former resident (R10) was lawful. The resident violated House Rules and Admission Agreement at least five times from 7/2019- 9/2019. Resident (R10) refused to sign the notice issued by Administrator Ana Giron. A staff witness was present when a copy of the eviction notice was given to the resident. The eviction notice reason stated, "Aggressive behavior toward staff and verbally abusive to other residents, containing drugs on premises, drinking in the facility, and sneaking visitors into rooms at all hours of the night." On 9/24/2019, resident (R10) attacked staff (S2) by grabbing its neck and attempting to choke staff. Downey Police responded to the incident, and the resident was taken to the hospital on a psychiatric hold. Upon hospital discharge the resident was not allowed back because it was past the effective date (9/28/21) of the eviction notice. The resident picked up personal belongings on 10/23/2021. Staff interviews revealed that the resident's room "always smelled like chemicals", and always had cleaning agent Clorox in the room." Resident interviews confirmed that R10 had history of aggressive behaviors, misconduct, and drug use on the premises.

Allegation: "Staff failed to safeguard residents belongings." It is alleged that resident (R10's) personal belongings i.e. paperwork was "thrashed", crystal vase and phone were broken and missing, and that the resident did not everything back on 10/23/2019 when belongings were picked up. A copy of LIC 621 "Client/Resident Personal Property and Valuables" was obtained. Resident (R10) signed the document dated 10/23/2019 stating "All belongings have been picked up. No belongings have been left behind. CID (Country Inn of Downey) is no longer responsible for these items." Per staff interviews, when a resident is not at the facility or is hospitalized their room is locked for safe keeping on belongings. On 9/28/2019, resident called the facility and was informed that its belongings would be held for 2 weeks. Staff denied not safeguarding the resident's belongings during its absence. Six (6) out of nine (9) residents stated their belongings are safeguarded and have not had any issues. Three (3) out of nine (9) residents reported that there have been issues with articles of clothing not being returned after washing, some clothing items have been damaged and/or lost, and that resident's belongings are at times taken from the room. Staff stated that R10's were not damaged or missing, and staff are instructed to deep clean resident's rooms. Therefore some items may be removed if deemed to be unsanitary and/or a hazard. There is insufficient evidence to corroborate this allegation.

Report continues- LIC 9099C
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20200102164741
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: 12/01/2021
NARRATIVE
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Allegation: "Resident not awarded privacy." It is alleged that resident (R10's) room door was not secured; thus the resident had to buy a door stopper to keep people from entering the room. According to staff interviews, staff protocol is to knock before entry, and upon exit lock the resident's door. Staff stated that the resident was not allowing housekeepers to clean the room, and would act aggressively towards staff when they attempted to clean the room. All staff denied the allegation. Six (6) out of nine (9) residents stated the facility respects and awards privacy. Three (3) out of nine (9) residents stated the facility does not award privacy because most resident's must share a room, and there are times that staff walk into the rooms without knocking. It is alleged that one day resident (R10) woke up and "someone" was using its bathroom. However, video surveillance shown to LPA revealed that on July 8, 2019 at 5:24 AM, an adult male identified as a known friend of R10 was seen exiting R10's room naked running through the 1st floor hallway. The unauthorized male is homeless and a suspected drug user whose mother resides at the facility. There is insufficient evidence to corroborate this allegation.

Allegation: "Staff sent resident to hospital under false pretenses." Based on interviews conducted and record review the findings indicate that on 9/24/2019 resident (R10) was taken to a psychiatric hospital per PET (Psychiatric Evaluation Team) after resident's verbal and physical aggression towards staff (S2)that caused injury. Resident (R10) denied assaulting staff. However, there were staff and resident witnesses present during the incident. The resident was transported to the hospital with justifiable reason, and remained hospitalized until mid October 2019. Incident reports were obtained.

Allegation: " Staff did not provide a safe environment for resident." Based on interviews conducted, review of video surveillance, and review of records and pictures the findings indicate that the alleged unauthorized male visitor whose mother resides at the facility is allowed entry into the facility by resident (R10) during late night time hours. The male visitor is suspected to be a drug user whom R10 frequently brought into the room. Video surveillance footage depicted R10 allowing the male visitor into the room after visiting hours. Seven (7) out of nine (9) residents stated the facility provides a safe environment for residents. Two (2) out of nine (9) residents reported that resident (R4's) son/unauthorized male that visits R10 harassed other residents by begging outside the facility building. Resident (R4) stated that its son did not harass any residents during visits. Staff reported that R10 often engaged in verbal altercations with other residents, and if a resident responded back it was construed as harassment by R10. Resident (R11) denied harassing resident (R10).

See LIC 9099C for report continuation.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20200102164741
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: 12/01/2021
NARRATIVE
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CONTINUATION of Allegation: " Staff did not provide a safe environment for resident."

Staff stated that all visitors are provided a visitor sticker upon sign in entry. Staff are instructed to check for visitor stickers. Staff stated the side door is kept unlocked during daytime hours, and is locked after 5:00 PM. Staff stated they make sure it is closed at night. Staff reported that R10 often went to the side door by the kitchen and open the gate for friends. The side door by the kitchen door is kept unlocked during the day. At night the metal gate outside the door is locked. All facility exit doors are locked at 9:00 PM. It is alleged that R10 felt harassed by resident (R11), but R11 denies harassing the resident. However this allegation cannot be supported by evidence.

Based on interviews conducted, record review, and LPA observations there is insufficient information to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview conducted with Med-Tech Erika Becerra. A copy of the report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4