197803745-10-15-2024-28-AS-DSIS-DA6TVH-20241018150358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:49:44 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
10/09/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241009123809

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: 75	DATE:	10/15/2024
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Erika Becerra - Med-Tech/Assistant Administrator		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is in disrepair.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Erika Becerra (Med-Tech/Assistant Administrator) and explained the purpose of today's visit. Shortly after LPA met with Administrator Ana Giron who assisted with the investigation.

The investigation consisted of the following:

LPA obtained copies of staff & resident rosters. LPA tested the Emergency Elevator button and obtained a copy of the last service that was done on elevator. Tour of Restident #1's (R1) room was conducted. LPA interviewed 5 Staff and 9 Residents.

(Continued on LIC9099-C)

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: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

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-20241009123809

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: 10/15/2024

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: Facility is in disrepair.

It is alleged that the elevator emergency alarm button is not in working order, it was tested by R1 and there was no sound. LPA interviewed Administrator and it was stated that the elevator is serviced monthly and there have been no reports of the emergency button not working. 2 out of 9 residents interviewed stated that there have been occasions where they pressed the emergency alarm button and there was no response, no alarm sounded and appeared to be non-operable.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20241009123809

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: 10/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/29/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This standard is not met as evidence by:	1 2 3 4 5 6 7	Licensee/Administrator to have Elevator Serviced and repair must be made to elevators emergency alarm button by POC due date. An invoice showing repairs have been completed to be emailed to LPA by POC due date. tena.herrera@dss.ca.gov
	8 9 10 11 12 13 14	During visit LPA inspected the elevators emergency alarm button and when button was pushed, there was no sound, no lights, no idication that the emergency button was pressed, which poses a potential health, safety or personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3