197803745-2-2-2024-28-AS-BPEA-D23UN5-20240202144319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803745
Report Date: 02/02/2024
Date Signed: 02/02/2024 02:46:37 PM

Document Has Been Signed on 02/02/2024 02:46 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 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: 66	DATE:	02/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Erika Becerra - Med Tech		TIME COMPLETED:	03:00 PM

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	Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Med Tech, Erika Becerra and Receptionist, Patricia Hernandez and explained the purpose of the visit. There are currently (66) residents, 60 years and older residing in the facility, of which (2) are under hospice care, no bedridden. Facility has approved hospice waiver for (5) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located at the reception area. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan is up to date. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has not been added to the Plan. Administrator agreed to update the Plan of Operation to include the Infection Control Plan. The facility does not have a Dementia Waiver in place. A maximum of (70) non-ambulatory residents may be in the facility. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 04/01/2024. Surety bond of $20,000.00 is current. Fire drill is conducted every (6) months and was last conducted on 01/08/2024. Physical Plant/Environment Safety: The facility is a 2-story building with a basement located in a residential community. The facility consists of: Basement: Laundry room, Staff lockers, (2) Housekeeping Supplies rooms, Elevator room, and Boiler room. First floor: Lobby/Reception area, Administrative offices, Medication room, (1) Elevator, Dining room, Board room, Kitchen, Pantry for emergency food supplies, Activity room, TV room/Resident lounge, PPEs Storage room, Courtyard/Smoking area, and (32) resident bedrooms. Second floor: (46) resident bedrooms, and Medical office. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Between 11:00am-12:30pm, LPA inspected (12) random resident bedrooms and tested hot water temperature in rooms (Rooms #2, #12, #18, #24, #25, #28, #35, #40, #47, #64, #66 and #81) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Fire service inspection was conducted and total of (23) fire extinguishers were serviced/refilled on 01/09/2024 by DOR Fire Service Inc. LPA observed cameras in the common areas and hallways.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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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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
	VISIT DATE: 02/02/2024

NARRATIVE

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Staffing: A total of (29) staff members provide care and supervision to the residents, including the Administrator. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records-Training: Seven (7) staff files were reviewed. Proof of staff training, health clearance, vaccinations, food handling certificates, and 1st Aid/CPR training are current. Administrator's certificate is valid and will expire on 10/20/2024.

Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection.

Exit interview conducted and a copy of this report was provided to Erika Becerra, Med Tech.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC809 (FAS) - (06/04)

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