197803745-9-19-2023-28-AS-DSIS-CVWPTB-20230922113537

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 09/19/2023
Date Signed: 09/19/2023 01:03:56 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
09/18/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230918084919

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: 65	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Ana Y. Giron - Administrator		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Staff do not respond in a timely manner to residents' calls for assistance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit to investigate the above allegation. LPA met with Patricia Hernandez, Receptionist and explained the purpose of today's visit. At 10:30am, Ana Y. Giron, Administrator arrived and assisted LPA with the investigation.

The investigation consisted of the following: LPA obtained copies of staff & resident rosters, Caregivers schedule and Receptionist/Admin Asst. duties and responsibilities. LPA interviewed Staff #1 (S1) - Staff #5 (S5), Resident #1 (R1) - Resident #8 (R8) and toured the facility's common areas. Assisted by the receptionist, LPA observed and tested the intercom service located in the front office by calling the caregivers. At 12:10pm, LPA also went to test intercom service and called for caregiver's assistance in one of the resident rooms (Room #6).

The investigation revealed the following:
In regards to the allegation: "Staff do not respond in a timely manner to residents' calls for assistance." It is alleged that residents are not assisted right away and believes it's due to lack of staff. Residents are left sitting on the toilet for appx. 30 minutes after the residents ask for assistance. ***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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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-20230918084919

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: 09/19/2023

NARRATIVE

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(5) of (5) staff interviewed denied the allegation. Interviews with staff stated that if caregivers are busy or on an emergency call, other staff members come to help the residents right away. Staff interviewed stated that they have enough staffing, (2) caregivers plus Med Tech are on duty per shift. Assisted by S2, LPA observed and tested the intercom service located in the front office by calling the staff and staff responded to the call immediately. LPA along with S1 entered a random resident room (Room #6) unknown to the staff and called for assistance through the intercom. Staff arrived in the room in less than a minute to check. (7) out of (8) residents interviewed could not corroborate the allegation. Interviews with residents detail staff responses from intercom call buttons to be immediate and under 5 minutes. Residents indicated that caregivers come to assist them right away, depending on how busy they are, residents don't wait too long for assistance.

Based on observations, statements and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview, a copy of this report was provided to the Facility 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: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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