197803745-1-9-2025-28-AS-RORN-DCWR2T-20250114113851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:32:14 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
01/02/2025 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250102130055

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:	01/09/2025
		UNANNOUNCED	TIME BEGAN:	10:58 AM
MET WITH:	Erika Becerra - Med-Tech/Assistant Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not ensure residents medications were properly managed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. 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 visit.

The investigation consisted of the following:
LPA obtained copies of staff & resident rosters, reviewed 10 Residents Medications and interviewed 2 Staff (S1-S2) and 8 Residents (R1-R8).

(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: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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-20250102130055

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: 01/09/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not ensure residents medications were properly managed.

It is alleged that R1 ran out of their prescribed inhaler on 1/2/25 and staff are having trouble getting the prescription refilled. LPA reviewed 10 residents medication and 9 out of 10 residents medications were properly labeled, accounted for and appeared to be administered per physicians orders. LPA noticed that R9's medication bubble pack still had the am medications for 1/9/25 in the package at 12pm, when LPA asked S2 what happened to the medication it was determined that there was a medication error and R9 missed their morning medication for 1/9/25 (citation will be issued and detailed in the LIC9099-D page). LPA interviewed 8 residents and 7 out of 8 residents stated that they haven't had any missed medications or experienced their medication missing/not being refilled in a timely manner and believe staff are administering medication per physicians orders.

Based on LPAs observations during medication review, 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 this report and 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: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250102130055

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: 01/09/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/10/2025 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator/Licensee to conduct a medication training for all staff that assist with administering medications. A copy of the training materials, scheduled date of training and list of participants to be emailed to LPA by end of day 1/10/24. Administrator to send LPA a copy of the signed participant list once training is completed (training to be conducted no later than 1/23/24).
	8 9 10 11 12 13 14	While LPA was reviewing medication 1 out of the 10 residents medications reviewed appeard to have missed their am medications as the bubble pack for R9's AM medications (for 1/9/25) were still in bubble pack, S1 investigated this error and it was discovered that the medication was missed as the medtech from the evening shift (on 1/8/25) experienced an emergency in the middle of prepping meds for the following morning (1/9/25) and did not pop the medications, causing the medication to be missed in the moring of 1/9/25. This error was discovered at approx. 12:40pm on 1/9/25.	8 9 10 11 12 13 14
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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: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

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