197803745-10-22-2024-28-AS-DSIS-DADN36-20241025100546

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 10/22/2024
Date Signed: 10/22/2024 03:13:06 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
10/18/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241018163747

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:	10/22/2024
		UNANNOUNCED	TIME BEGAN:	11:06 AM
MET WITH:	Erika Becerra - Med-Tech/Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are mismanaging resident's medication.
Staff are not ensuring resident was seen by a physician.
Staff are not preventing resident from falling.

INVESTIGATION FINDINGS:

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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 obtained the following copies from Resident #1's (R1's) file: Admission Record, Physician Reports, Medication List, Lab Results Paperwork and Doctor Evaluation Notes. LPA reviewed Medication Room and inspected R1's medication along with R6-R8's Medications. LPA interviewed 8 Residents, 2 Staff and Facilitys Doctor during todays visit.
(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: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

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-20241018163747

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: 10/22/2024

NARRATIVE

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The investigation revealed the following:
Allegation: Staff are mismanaging resident's medication.
It is alleged that R1 is not getting their medications, and it was allegedly said by MedTech (S1), that R1 that came to the facility with no medications or orders upon admission, and that on 9/9/24 when R1 was discharged from the hospital R1 had been discharged with medications. LPA reviewed Admission Record (discharge paperwork from previous placement) and there were no medications attached to the paperwork. LPA spoke with Administrator and S1 and both denied the above allegation and stated that when resident was admitted there were no medications or medication list sent with R1. Both staff further stated that R1 has seen a doctor since being admitted and has been prescribed 2 medications in which resident is taking daily. LPA reviewed R1's medication list along with medication and did not observe any issues. LPA spoke to facility doctor during todays visit and doctor stated that resident has been seen by them both today (10/22/24) and on 9/11/24, medication has been prescribed and lab work has been ordered for R1. LPA interviewed a total of 8 residents during todays visit and 4 out of 8 residents stated they have never had any issues with their medication and feel that their medication is being administered per doctors orders. LPA reviewed the remaining 3 residents (R6-R8) medication lists and medications and did not observe any issues. S1 stated that although there may have been slight issues with medication being ordered before the cycle ended, as pharmacy's have been switched, they were able to order the medication with the previous pharmacy to ensure there was no lapse in medications. LPA was able to review medication and confirm there has been no lapse.

Allegation: Staff are not ensuring resident was seen by a physician.
It is alleged that R1 hasn’t seen a doctor. LPA reviewed R1's file and observed both the physicians report upon admission and physician report completed by the facility doctor on 9/11/24. LPA interviewed facility doctor and it was stated that they had visited with resident both on 9/11/24 and today 10/22/24, there have been medications prescribed to R1 during the initial visit and today labs have been ordered for R1. LPA interviewed 2 staff and both denied the above allegation and stated that residents at facility are assisted with seeing a physician (if needed, as some are self-responsible and have their own primary physicians) and that there is a facility doctor who visits regularly/monthly. LPA interviewed a total of 8 residents during todays visit and 7 out of 8 residents denied the above allegation and stated that they see their doctor often and have never had issues being seen by a physician.
(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: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20241018163747

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: 10/22/2024

NARRATIVE

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Allegation: Staff are not preventing resident from falling.
It is alleged that R1 was not getting physical therapy and had a couple of falls which made them scared to fall again. LPA interviewed R1 and R1 stated that they did experience a slip/fall at facility, couldn't recall when, but that staff did assist them and they did not need to be sent to the hospital. LPA interviewed 2 staff and the facility doctor all denied the above allegation and stated that R1 has never mentioned any falls at facility since admission and that if or when there is a fall, immediate attention is given and ambulance is called if needed. Staff further stated that R1 was not receiving physical therapy upon admission and have not observed that R1 is in need of physical therapy. LPA interviewed a total of 8 residents and 8 out of 8 residents denied the above allegation and stated that staff do respond rapidly if there is a fall and give the residents immediate attention if they fall.

Based on statements and interviews conducted with staff, and residents, review of R1's files and Review of Medications, there was not enough supportive evidence to concur with the reported allegations.

Although the allegation may have happened or is 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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

LIC9099 (FAS) - (06/04)

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