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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803745
Report Date: 02/03/2024
Date Signed: 02/03/2024 01:17:23 PM


Document Has Been Signed on 02/03/2024 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 DOWNEYFACILITY NUMBER:
197803745
ADMINISTRATOR:ANA YESENIA GIRONFACILITY TYPE:
740
ADDRESS:11111 MYRTLE ST.TELEPHONE:
(562) 869-2401
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:150CENSUS: 66DATE:
02/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ana Y. Giron - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent visit for annual continuation. LPA met with Erika Becerra, Med-Tech who assisted with the inspection. The initial required-1 yr inspection was conducted on 02/02/2024. During the initial visit, Ana Y. Giron, Administrator also assisted LPA with the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools today for the remaining domains and observed the following:

Resident Rights-Information: Resident personal rights/non discrimination notice, complaint hotline information and visitors policy posters are posted in the lobby. Per Administrator, facility provides internet services to all residents and have access to the facility phone.
Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted in the hallway next to the TV room/Resident's lounge. Currently, the facility does not have a Resident Council. According to the Med Tech, after Covid, none of the residents are interested to join the council, but they will continue to encourage residents to form a council.
Food Service: Sufficient food supply is stored in the kitchen consisting of: 2-day perishables, 7-day non-perishables. A separate pantry area stores the emergency food and incontinence supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Incident Medical and Dental: A total of ten (10) centrally stored resident medications were reviewed; containing 30-day supply of medications. Facility uses eMar called point-click to document residents medications. Most medications are bubble packed. A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided.
Resident Records/Incident Reports: A total of ten (10) resident files were reviewed. They contained Identification and Emergency Information, Admission Agreements, Physician's Reports, Pre Placement Appraisal, Resident Appraisal, Service and Needs Plans, Personal Rights, Residents Personal Property and Valuables, TB clearance, Functional Capability Assessment, and Medical Consent.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training.
Residents with Special Health Needs: Eleven (11) residents are receiving home health services. Two (2) residents receive hospice care. LPA observed that there are 2 residents (R1/R2) under hospice care but CCL/Licensing was not notified in writing of the initiation of hospice care services.


Per California Code of Regulations, Title 22, deficiency was cited and Technical Assistance issued.

Exit interview conducted and a copy of the report and appeal rights were provided to Ana Y. Giron, Administrator.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2024 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(d)(2)
Hospice Care Waiver
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the Administrator did not comply with the section cited above in which there are currently (2) residents (R1/R2) under hospice care and CCL/Licensing was not notified in writing of the initiation of hospice care services which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 02/16/2024
Plan of Correction
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Administrator will submit notice of initiation of services to CCL/Licensing for the (2) residents currently on hospice by POC due date. Notice shall include the residents’ names, dates of admission to the facility and the name and address of the hospice.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2024
LIC809 (FAS) - (06/04)
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