197803745-11-9-2023-28-AS-DSIS-CXNVLG-20231117153156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 11/09/2023
Date Signed: 11/09/2023 04:03:48 PM

Substantiated

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
11/03/2023 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231103125227

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:	11/09/2023
		UNANNOUNCED	TIME BEGAN:	12:27 PM
MET WITH:	Erika Becerra - Assistant Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Licensee is financially abusing former resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. 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:
LPA obtained copies of staff & resident rosters, reviewed Residnet #1 (R1's) file and obtained the following copies from thier file: ID information, Physician Report, Resident Personal Property and Valuables Log, Admission Agreement, Notice of funds refunded to R1 on departure date, and R1's 30-day moving notice. LPA conducted interviews with R1, Administrator at R1's current residence (another licenced facility), and interviews with the 2 administration staff (S1 & S2) that handle payment at Counrty Inn of Downey.

(Refer to LIC 9099C for the continuation of this report)

Substantiated

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: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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-20231103125227

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: 11/09/2023

NARRATIVE

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The investigation revealed the following:
Allegation: Staff are financially abusing client.
It is alleged that licensee has not forwarded payments that have been received for R1 from July 2023 - September 2023. LPA reviewed R1's file and observed 30-day notice was provided to facility on 5/13/23 and R1's departure date was 6/13/23. R1 also removed all belongings from facility on 6/13/23 and LPA obtained a copy of statement with signatures from R1 and administrator confirming belongings were removed. R1 was issued a partial refund for balance of rent and withdrew Personal and Incidental Money (PNI) funds in full on 6/13/23. Based on interviews with R1 and administrator at R1's new licensed facility, the new facility was not made payee to R1's Social Security Income (SSI) until mid October 2023, no payments were received prior to 10/13/23 to the new facility. Based on interview with Administrator Ana Giron, facility did received payments for R1 for months of July - September 2023. Administrator stated that no call was made to Social Security until August when Administrator became aware that SSI Money was still being deposited into corporate account. Administrator stated that while updating records in August is when she became aware of the deposits and July/August record reviews were conducted done together giving the reason for delay in calling Social Security Office. Administrator stated she did not inform SSI right away of residents departure from facility as resident stated they would take care of the switch and that their new facility will be handling all paperwork with Social Security. Administrator stated that she will be personally visiting the Social Security Office on Wednesday November 15, 2023 to provide a refund check in for the total amount deposited into the corporate account during months of July-September 2023 and Social Security will then be in charge of forwarding those payments to the new payee. Based on interview conducted with both Administrator and S2, when a resident departs from facility it is duty of administration to ensure that SSI becomes aware of switch to avoid continued payments to the licensee. Administrator stated in this case since R1 stated they would be taking care of the change no call was made to Social Security prior to August. The delay of monies returned to R1 or SSI and of urgency to contact SSI upon R1's departure from facility corroborates this allegation.

Based on LPA's observation and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

California Code of Regulations, title 22 are being cited on the attached LIC 9099D

Exit interview conducted, appeal rights and a copy of this report was provided to Victor Ortiz.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231103125227

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 11/23/2023 Section Cited CCR 87217(i)	1 2 3 4 5 6 7	Safeguards for Resident Cash, Personal Property, and Valuables (i) Upon discharge of a resident, all cash resources, personal property and valuables of that resident which have been entrusted to the licensee shall be surrendered to the resident, or his responsible person. A signed receipt shall be obtained.	1 2 3 4 5 6 7	Administrator stated that she will personally refund total amount deposited into the corporate account during months of July-September 2023 on Wednesday November 15, 2023 and Social Security will then take charge of forwarding payments to the new payee. Proof to be submitted to LPA via email by POC due date.
	8 9 10 11 12 13 14	This standard is not met as evidence by: Per interview with Administrator Ana Giron facility continued to receive payments after R1's departure, payments were received for months July-Sept 2023. Administrator did not notify SSI of departure until August. The delay of monies returned to R1 or SSI and of urgency to contact SSI upon R1's departure from facility corroborates this allegation.	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC9099 (FAS) - (06/04)

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