197803745-1-9-2025-28-AS-RORN-DCWR2U-20250114113851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:30:31 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
01/02/2025 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:	02:20 PM
MET WITH:	Erika Becerra - Med-Tech/Assistant Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff do not ensure resident is accorded personal privacy.

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 and interviewed 2 Staff and 8 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: 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)

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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
	VISIT DATE: 01/09/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff do not ensure resident is accorded personal privacy.

It is alleged that the licensee/administrator allowed the police to install spy cameras in R1’s bedroom/bathroom fixtures, and a 2-way mirror in R1’s bedroom for police to be able to spy on R1. LPA toured R1's room along side of R1 and did not observe anything that appeared to be spyware within the room. LPA interviewed 2 staff and both staff denied the above allegation, they confirmed that this has been an ongoing accusation made by R1 and both staff and law enforcement (along with licensing in recent visits) have investigated this accusation and have not found any signs spyware being in R1's room. LPA interviewed R1 and resident stated that they still feel as though they are being watched, resident confirmed that law enforcement visited them on 1/3/25 and did not find any spyware in their room. LPA interviewed a total of 8 residents and 7 out of 8 residents denied the above allegation and stated that they do not feel as though they are being spied on by staff and feel staff provide them with privacy.

Based on statements and interviews conducted with staff and residents, along with tour LPA conducted with R1 in their private room, 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 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: 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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