197803745-10-15-2024-28-AS-DSIS-DA6TVJ-20241018150358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:48:56 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
10/09/2024 and conducted by Evaluator Tena Herrera

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:	01:57 PM
MET WITH:	Erika Becerra - Med-Tech/Assistant Administrator		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not according privacy to resident in care.

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)

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: 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 2

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: Staff are not according privacy to resident in care.

It is alleged that staff are not giving the residents privacy at the facility and intentionally listen in on personal phone calls. LPA interviewed 5 staff and 5 out of 5 staff stated that they do not deny privacy to residents and have never listened to a residents phone call. 3 out of 5 staff stated that there have been times that a resident is on a phone call when they enter their room but they give them privacy and return at a later time. Interview with Administrator and Staff #1 (S1), both stated that there are landline telephones and a pay phone that is available for residents who do not have cellular phones to use, both also stated that there is no other receiver that can be used to listen in on the phone call when the phone(s) are in use. LPA interviewed 9 residents and 7 out of 9 residents denied the above allegation and stated they have never been denied privacy and have never experienced staff listening in on their personal phone calls.

Based on statements and interviews conducted with staff and residents, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was 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 2