197803745-6-18-2024-28-AS-RORN-D6KVEN-20240625162237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 06/18/2024
Date Signed: 06/18/2024 10:07:20 AM

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
05/20/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240520150448

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: 62	DATE:	06/18/2024
		UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Erika Becerra - Assistant Administrator/MedTech		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff disguised non prescribed medications in residents’ food.
Staff did not ensure medications were dispensed as prescribed.
Staff did not ensure residents were spoken to in an appropriate manner.
Staff did not ensure the facility was kept free of pests.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit to deliver findings on the above allegations. LPA met with Erika Becerra (Assistant Administrator/MedTech) and explained the purpose of today's visit.

The investigation consisted of the following:
During the initial visit conducted on 5/28/2024, LPA obtained copies of staff & resident rosters, LPA toured facility alongside of Erica Becerra, Medication Room (Med Room) was toured, LPA reviewed a total of 10 residents’ medications, a total of 7 bedrooms were toured, 3 on 1st floor and 4 on 2nd floor, bedding and mattresses were inspected. LPA interviewed 5 staff (S1-S5) and 10 residents (R1-R10). Due to time constraints, the above allegations needed further investigation.

During todays visit LPA met with Erika Becerra, discussed above allegations and delivered findings.
(Continued on LIC9099-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: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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 3

Control Number 28-AS-20240520150448

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: 06/18/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Investigation Revealed the Following:
Allegation: Staff disguised non prescribed medications in residents’ food.
It is alleged that staff were putting sleeping medication in the food to make the residents fall asleep, which caused some residents to feel symptoms of racing heart beats. LPA observed medication administration during the first round of afternoon lunch/medication at 11:45am, this was done in the dining area and all medication was dispensed in their own cups labeled for each resident and LPA reviewed medication with doctors’ orders and all seemed to be administered per doctors’ orders. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation. 2 of the 5 staff interviewed are Medication Technicians and are able to administer medications and both stated they have never given a resident medication that is not prescribed for them, they also stated that there are many residents who do take medication to help with sleep, but it is doctor ordered and prescribed to that individual. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation, some stated that they do take sleeping medication but that it has been prescribed to them by their doctor, all residents stated that medication administered to them are doctor ordered.
Allegation: Staff did not ensure medications were dispensed as prescribed.
It is alleged that the staff give the wrong medications to residents. LPA reviewed 10 residents’ medications in medication room, all were properly labeled in their designated areas, each residents medication were in their own cubbies that are labeled and had each residents photo, PRN medication was stored in a separate cabinet, also properly labeled and in original containers. LPA observed medication being administered at 11:45am with no issues. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation, 2 of the 5 staff were MedTechs and they stated that their medication process is very thorough and leave little to no room for errors, since the medication is securely stored and labeled very clear. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation. 7 out of 10 residents stated that they look at the medication before they consume it, residents stated their medications are always consistent, and they never have reason to question the medication. 3 out of the 10 residents interviewed stated that they once observed a questionable medication and brought it to the MedTechs attention, it was then determined that the medication was correct, their pharmacy had changed the color/shape of the medication which is what made them question it.

(Continued on LIC9099-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20240520150448

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: 06/18/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff did not ensure residents were spoken to in an appropriate manner.
It is alleged that the staff yell at the residents. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated they have never yelled at a resident, nor have they witnessed another staff yell at any of the residents. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation and stated that the staff are friendly and have never yelled at them nor have they observed staff yelling at any other resident.
Allegation: Staff did not ensure the facility was kept free of pests.
It is alleged that the facility had issues with bed bugs and scabies. LPA toured facility total of 7 bedrooms were entered, beds and linens were inspected and there was no evidence of bed bugs, all beds had plastic cover, mattress pad, sheets, blanket and comforter. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that they have not had any observations of scabies or bedbugs within the facility. Staff also stated that they have not observed any scabies outbreaks or residents with scabies. 3 of the 5 staff interviewed work directly with the bedding and stated they have never observed any bed bugs on any of the linens or mattress when making beds or when changing the sheets for weekly cleaning. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation and stated that they have not observed any bed bugs and do not know of any issues with scabies in the facility.

Based on statements and interviews conducted with staff and residents, a review of resident medications and tour of the facility, 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: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3