197803745-12-12-2023-28-AS-MVAO-CYWV4D-20231227150611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:41:32 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
11/09/2022 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221109102338

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: 63	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Erika Becerra - Assistant Administrator/MedTech		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not provide resident with copies of admission paperwork.
Staff denied resident from using their motorized wheelchair.
Staff did not ensure resident had hot water for showers.
Staff did not ensure residents room was free from pests.
Staff did not ensure residents thermostat was working properly.
Staff did not ensure residents plusg are working properly.
Staff did not ensure residents motorized wheelchair stayed charged.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent unannounced complaint visit to investigate the above allegations. LPA met with Receptionist Patricia Hernandez and explained the purpose of today's visit, Assistant Administrator Erika Becerra later assisted with the visit.

The investigation consisted of the following:
During initial visit conducted on 11/16/2022, LPA Glen Truman obtained resident/ staff roster and various documents from R1's file.LPA interviewed Administrator and R1, due to insufficient information at the time the allegations needed further investigation.

During subsequent visit conducted 12/12/23, LPA Herrera obtained copies of the Staff and Resident Rosters, R1 Physician Report, R1 Signed House Rules, Monthly Pest Control Invoices (dated 9/2022 - 11/2022) and Repair Statement on Repairs Done in R1's room. LPA interviewed 4 Staff (S1 - S4), 9 Residents (R1 - R9) and toured facility. (Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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-20221109102338

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: 12/12/2023

NARRATIVE

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The Investigation Revealed the Following:

Allegation: Staff did not provide resident with copies of admission paperwork.
It is alleged that staff were reluctant on providing copies of admission agreement and physician report to R1. Interviews with 4 Staff, 4 out of 4 staff denied the above allegation, 3 staff stated that R1 has asked for copies of paperwork and each time copies have been provided to them. Interviews with 9 Residents, 8 out of 9 residents denied the above allegation and stated that either they were provided copies of their admission paperwork upon admission or that they can't remember but feel confident that the staff will provide them with copies if they were to ask. R1 stated that as of now they do have copies of their admission paperwork and their physician report.

Allegations: Staff denied resident from using their motorized wheelchair. Staff did not ensure residents motorized wheelchair stayed charged.
It is alleged that staff does not allow R1 to use their motorized wheelchair and the location used to store the motorized wheelchair does not have an outlet to charge them, therefore, wheelchairs remain uncharged. LPA reviewed Facility House Rules (signed by R1) and within the house rules it does indicate that "Unless special arrangements have been made; electric wheelchairs and other personal motorized transportation equipment are not allowed in the facility". LPA reviewed R1's Physician Report and it does not indicate that R1 must use an electric wheelchair to ambulate. Interviews with 4 Staff, 4 out of 4 Staff deny the above allegation and state that R1 is able to use their electrical wheelchair and charging is done within R1's private bedroom. S4 stated that in the case that their is no room in a residents bedroom, residents are able to store and charge their electrical wheelchairs in the facility basement. LPA interviewed R1 in their bedroom and observed two electrical wheelchairs one that they were using and another stored in room, R1 indicated that they are able to use their electrical wheelchair in the facility. Interviews with 9 Residents, 8 out of 9 Residents deny the above allegation and stated that they have never been denied access to their medical equipment, including but not limited to wheelchairs.

(Continued on 9099-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20221109102338

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: 12/12/2023

NARRATIVE

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Allegation: Staff did not ensure resident had hot water for showers.
It is alleged that the water in R1's shower takes 7-8 minutes to get warm and the water temperature does not get hot. LPA toured facility and tested water temperature in 6 Resident Private Bathrooms all of which were within the required range of 105-120 Degrees F and LPA observed water to reach warm temperature within 1-2 minutes. Interviews with 4 Staff, 4 out of 4 Staff denied the above allegation and stated they have not heard of complaints on the water temperature. S1 stated that maybe in the early morning it may take a little longer than usual for water temperature to warm but it will heat up within 1-2 minutes. Interviews with 9 Residents, 8 out of 9 Residents deny the above allegation and stated that their bathrooms do receive hot water, and stated that early morning the water does tend to take a while to get warm but it takes no more 1-2 minutes.

Allegation: Staff did not ensure residents room was free from pests.
It is alleged that there are roaches and spiders in R1's room. LPA toured 6 Resident rooms and did not find any evidence of pests, roaches or insects in any of the rooms/restrooms. Interviews with 4 Staff, 4 out of 4 Staff denied the above allegation and stated they have not had any complaints of pests in resident rooms. Interviews with S1 and S4 indicated that R1 did mention to them that they had insects in their room but when toured they did not find evidence of any insects/roaches, both staff stated as a precaution there was a pest control service called in and provided LPA with invoices of pest service from dates 9/2022 - 11/2022. Both staff further indicated that there was a repair made to R1's door to close any gaps there may have been and provided LPA with Repair Statement. Interviews with 9 Residents, 7 out of 9 residents stated that they have never had any issues with roaches/insects or pests in their rooms.

(Continued on 9099-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20221109102338

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: 12/12/2023

NARRATIVE

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Allegation: Staff did not ensure residents thermostat was working properly.
It is alleged that the temperature in R1's room is not comfortable as it is either too hot or too cold in the room and the thermostat has incorrect readings. LPA toured facility and observed 5 thermostats (2 upstairs and 2 downstairs one in R1's room) each thermostat was within the required range, reading ranged from 69 degrees F - 77 degrees F. The thermostat in R1's room measured at 73 degrees F. Interviews with 4 Staff, 4 out of 4 staff denied the above allegation and stated that the temperature throughout the facility is maintained at a comfortable temperature and if a resident asks for the temperature to be raised or lowered they accommodate the resident. There are a total of 4 different air conditioner units that heat/cool different rooms. Interviews with 9 Residents, 8 out of 9 Residents denied the above allegation and stated that the temperature is comfortable throughout the facility. 2 out of 9 Residents stated they get cold easily and use a space heater instead of raising the temperature and making others uncomfortable.

Allegation: Staff did not ensure residents plugs are working properly.
It is alleged that there is a plug/outlet in R1's room that gets extremely hot when things are plugged into it.
LPA toured R1's Room and outlets seem to be in working order, R1 stated that the outlet issue has since been resolved. LPA toured 6 Resident Bedrooms and all outlets in bedrooms were in working order. Interviews with 4 Staff, 4 out of 4 Staff stated they have not had any complaints on outlets not working. S1 and S4 stated that they do recall R1 mentioning the outlet within their room not working and a repair was made quickly. Interviews with 9 Residents, 8 out of 9 Residents deny the above allegation and stated that they have never had any issues with their outlets not working in their rooms.

Based on statements and interviews conducted with staff and residents, and review of R1's files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to Erika Becerra.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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