197803745-7-12-2022-28-AS-FFIS-CGBU5T-20220714151712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:56:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/26/2020 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200826094719

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: 68	DATE:	07/12/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Ana Giron (Administrator)		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff is not providing resident with meals.
Staff did not respond to resident's call button in a timely manner.
Staff refuses to assist resident with meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Ana Giron (Administrator) and explained the purpose of the visit.

During the initial investigation conducted on 08/28/20, LPA interviewed Staff #1, Resident #1 and requested a copy of the Staff/Resident rosters, Needs and Services Plan, Admission Agreement, Appraisal, Incident Report and Physician's Report for Resident #1.

During today's visit, LPA obtained a copy of the Staff and Resident rosters, toured the kitchen with Staff #1, interviewed Residents #2 to #8 in the Sample Room and interviewed Staff #2 to #7 in the Sample Room.

Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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-20200826094719

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY INN OF DOWNEY	FACILITY NUMBER: 197803745
	VISIT DATE: 07/12/2022

NARRATIVE

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In regards to the allegation: Staff is not providing resident with meals. LPA toured the kitchen and observed sufficient food supplies for the current census. Interviews with 8 of 8 Residents indicate that breakfast, lunch and dinner is provided with snacks in between. Interviews with 7 of 7 Staff also indicate 3 meals a day is provided including snacks.

In regards to the allegation: Staff did not respond to resident's call button in a timely manner. Interviews with 7 of 8 Residents indicate Staff respond to the call button on a timely manner. Interviews with 7 of 7 Staff also indicate Staff respond to the call button on a timely manner.

In regards to the allegation: Staff refuses to assist resident with meals. A review of Resident #1's Physician Report and Resident Appraisal indicate Resident #1 does not require assistance with feeding. Interview with Resident #1 also indicate that Resident is able to self feed.

Based on LPA's observations and interviews, the investigation revealed: Although the allegations 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 conducted with Ana Giron and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC9099 (FAS) - (06/04)

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