197803745-10-31-2023-28-AS-LHIS-CXJPPM-20231113102945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:49:44 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
08/29/2022 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220829094205

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:	10/31/2023
		UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Ana Giron, Administrator		TIME COMPLETED:	04:04 PM

ALLEGATION(S):

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Facility did not safeguard resident's personal property
Administrator did not give accorded dignity in her personal relationships with resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent complaint investigation for the allegation listed above. LPA arrived unannounced and met with Staff, Erica Beccera, Med Tech. The purpose of the visit was explained. The administrator, Ana Giron, arrived a short time later to assist with the visit. Initial visit was on 09/06/2022

The investigation consisted of the following:
LPA obtained copies of the staff and resident rosters, R1 Inventory list at moveout, Interviews were held with 5 Staff S#1-S#5 (S1-S5) including Administrator, and 8 Residents R#1-#8 (R1-R8)

The investigation revealed the following:

(Continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
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-20220829094205

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: 10/31/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Facility did not safeguard resident's personal property. It is alleged that staff failed to return a wheelchair when resident moved out on June 24, 2021. LPA interviewed Staff and Residents regarding this allegation. Per Administrator, R1 had a moving van arrive at the facility around 12:34 PM on June 24^th, 2021, and R1 could not fit the second wheelchair in the van. R1 stated they would return to pick it up the wheel chair later. R1 returned at 4:30 that same day and took the 2nd wheelchair. R1 signed the inventory list acknowledging R1 had taken all R1's property and personal belongings, including both wheelchairs. LPA interviewed 5 staff and 5 of 5 staff denied the allegations. LPA interviewed 8 residents and 7 of 8 residents could not collaborate the allegations and all 7 of them stated they have never lost or had missing personal property. LPA did not find any evidence that the facility failed to give R1 all of their property.

Allegation: Administrator did not give accorded dignity in her personal relationships with resident. It is alleged that Administrator ignored R1 when inquiring about his wheelchair and threaten to call the police on him. LPA interviewed 5 staff including Administrator and 5 of 5 staff denied the allegations. LPA interviewed 8 residents and 7 of 8 residents could not collaborate the allegations. Several residents stated that Administrator is very kind and have never witness her been inappropriate with anyone. Some residents stated she is very kind with everyone. LPA could not find collaborating evidence to substantiate 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.

No deficiencies were observed or cited during the visit.

An exit interview was conducted with administrator Ana Giron and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
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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