197803745-8-29-2023-28-AS-RORN-CVTSSK-20230919140759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 08/29/2023
Date Signed: 08/29/2023 06:51:38 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:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Ana Y. Giron - Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff took inappropriate photos of resident without consent.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Patricia Hernandez, Receptionist and explained the reason for the visit. Administrator Ana Giron arrived shortly after and assisted LPA with the investigation.

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 today, 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) - Residnet #10 (R10). ***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: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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: 08/29/2023

NARRATIVE

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The investigation revealed the following:

Allegation 1: Staff took inappropriate photos of resident without consent. "It is alleged that a staff came into R1’s room and told her that they needed to take a picture of her catheter. It is also alleged that R1 was verbally forced by the staff and was threatened to be reported to the Administrator if R1 did not comply." Interviews conducted with six (6) staff members all denied the allegation and stated that they will never force any resident to do anything they do not want. S2 indicated that R1 was the one who called the staff to take a picture of her catheter’s leg bag because R1 wanted to replace or empty out her urine bag and to show S1 that R1 keeps herself clean. S3 stated that R1 refused to be assisted and cleaned even if her catheter bag was leaking all over the place. 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. R2 stated that R1's catheter bag was leaking in the room and has reported it to the staff. Nine (9) out of ten (10) residents interviewed denied the allegation. All nine stated that none of the staff had ever forced them to take a picture nor take their pictures without their consent. LPA's review of R1's file showed that R1 was self responsible and has Home Health Nurse who assists her.

Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, 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 and Appeals Rights were 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: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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