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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:23:50 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
01/13/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250113095523
FACILITY NAME:COUNTRY INN OF DOWNEYFACILITY NUMBER:
197803745
ADMINISTRATOR:ANA YESENIA GIRONFACILITY TYPE:
740
ADDRESS:11111 MYRTLE ST.TELEPHONE:
(562) 869-2401
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:150CENSUS: 74DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Erika Becerra - Med-Tech/Assistant AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff are not safeguarding resident's personal property.
Staff confiscated resident's nonprescription PRN medication without cause.
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 Administrator Ana Giron and explained the purpose of today's visit.

The investigation consisted of the following:

LPA obtained copies of staff & resident rosters, House Rules, and Admission Agreement. LPA reviewed a total of 5 residnets files including R1 to verify medication management. LPA interviewed 4 Staff (S1-S4) and 8 Residents (R1-R8).

(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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 2
Control Number 28-AS-20250113095523
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: 01/16/2025
NARRATIVE
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The investigation revealed the following:
Allegation: Staff are not safeguarding resident's personal property.
It is alleged that S3 rummaged through R1’s dresser, refrigerator and bathroom cabinets in search for R1’s wallet during a deep cleaning; and that several residents have reported that S3 has stolen money from them. LPA spoke with R1 and it was stated that they have never had anything missing from their personal belongings but has heard stories and doesn’t want to be a victim of theft. LPA reviewed house rules which includes that staff will deep clean and if potential hazardous items are found they will be confiscated, it also indicates that residents with a small refrigerator will be monitored for proper storage by staff. LPA interviewed 8 residents and 6 out of 8 residents denied the above allegation and stated they have not had any items stolen while living at facility and that they do not feel that staff invade their privacy by going through their belongings. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that per house rules deep cleaning is done once a week, when cleaning staff will open drawers to make sure there is no spoiled food, illegal substances or medication being kept in room and that they have never stolen any items from residents or have witnessed other staff doing this.
Allegation: Staff confiscated resident's nonprescription PRN medication without cause.
It is alleged that S3 was cleaning R1’s room and while cleaning S3 found over the counter medication and confiscated the medication, R1 allegedly does not have limitations that prevent them from having over the counter medication, is not on medication management and does not have a roommate or have medication stored where it is accessible to other residents. LPA interviewed R1 and they stated they purchased the medication at a local pharmacy. LPA reviewed R1’s file and it was observed that per physician report medication management is needed. LPA reviewed House Rules and it indicates that all medications must prescribed by physician and be centrally stored by facility (including PRN). LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that all medication at facility (including PRN) must be ordered by the physician and centrally stored in the medication room, if medication is found in a residents room it will be confiscated, taken to the medication room and explained why to the resident. LPA interviewed 8 residents and 7 out of 8 residents denied the above allegation and stated that they do not keep any medication, PRN or over the counter supplements/vitamins in their room and understand that the medication room holds all their medications.

Based on statements/interviews conducted with staff/residents, review of resident files, admission agreement and house rules, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are 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 will be emailed to Administrator.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
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