197803745-10-31-2023-28-AS-LHIS-CXEN4H-20231109090757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:36:13 PM

Unsubstantiated

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
11/21/2022 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20221121155057

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: 64	DATE:	10/31/2023
		UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Admninstrator Ana Giron		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Staff failed to meet resident's hygiene needs
Staff failed to safeguard resident's personal belongings
Staff leave resident in wet saturated clothes for extended periods of time
Staff are not taking precautions for COVID-19

INVESTIGATION FINDINGS:

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On 10/31/23 at 9:43 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent unannounced complaint visit regarding the above listed allegations. Upon arrival LPA met with the Med-Tech Ericka Becerra and explained the purpose of the visit. Administrator Ana Giron arrived at 11:34 and LPA explained the reason for the visit.

During the initial complaint, LPA was asked to check temperature and fill out a COVID questionnaire. LPA toured the facility with assistant administrator and observed all staff wearing a mask. LPA also observed the facilities Isolation zones in preparation for COVID. LPA toured R1’s bedroom. LPA obtained staff roster, resident roster, Infection control plan, 1 week of incontinence log, R1’s physicians report, R1’s Identification and Emergency information and photo of R1 clothing.

Report cointinued 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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-20221121155057

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: 10/31/2023

NARRATIVE

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During today’s visit LPA obtained the staff roster, resident roster, theft and loss policy, and interviewed seven (7) Residents who shall be referred to as R2 through R8. R1 moved out of the facility on 3/31/2022 and passed away on 4/11/2022. LPA also interviewed the administrator and four (4) staff who shall be referred to as S1 through S4.

The investigation reveals the following: Regarding “Staff failed to meet resident’s hygiene needs”. It is alleged that the facility left R1 unkept. The administrator Ana Giron denied the allegation stating all residents are cleaned and R1 was challenging but the facility persisted and assisted with keeping R1 neat clothing. 4 out of 4 staff stated that R1 was clean and had tiny holes due to R1 smoking. Whenever R1 made holes in his clothing, the facility looked for clothing to make sure he was clean. 5 out of 7 residents denied the allegation stating the facility took care of R1’s hygiene needs and R1 was combative. 2 out of 7 residents stated they do not remember R1, but the facility takes care of their hygiene needs. LPA reviewed R1’s incontinent logs dated 11-23-2022 through 11-28-2022 and confirmed R1 was changed three (3) times during the morning shift and three (3) times during the evening shift.

The investigation reveals the following: Regarding “Staff failed to safeguard resident’s personal belongings”. It is alleged that R1 was missing personal items. The administrator Ana Giron denied the allegation stating R1 was not missing items while living at the facility. 4 out of 4 staff stated that R1 was not missing items and has never complained to them about missing items. 6 out of 7 residents denied the allegation stating they are not missing items and has not heard other residents complained about missing items. 1 out of 7 residents stated they have been missing items and the issue has not been resolved.

The investigation reveals the following: Regarding “Staff leave resident in wet saturated clothes for extended periods of time”. It is alleged that the facility leaves R1 unattended in wet saturated clothing. The administrator Ana Giron denied the allegation stating all residents are cleaned and R1 was challenging but the facility persisted and assisted with keeping R1 clean. 4 out of 4 staff stated none of their residents has been left in wet or saturated clothing. 5 out of 7 residents denied the allegation stating they have never seen residents in wet clothing. 2 out of 7 residents stated they do not remember R1, but staff took residents to their rooms to get changed if they saw residents were incontinent.

The investigation reveals the following: Regarding “Staff are not taking precautions for COVD-19”. It is alleged that facility staff was not wearing masks and people were in an out of the facility without taking precautions. The administrator Ana Giron denied the allegation stating the facility followed COVD-19 protocols. 4 out of 4 staff stated the facility followed COVID protocols. 7 out of 7 residents denied the allegation stating the facility was following COVD-19 protocols.

Based on LPA's interviews, investigation revealed: 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 conducted with Ana Giron and a copy of this record provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

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