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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 06/05/2025
Date Signed: 06/05/2025 03:01:25 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
03/27/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250327161501
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: 82DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
02:52 PM
MET WITH:Erika Becerra - Assistant Administrator/Med-TechTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident sustaining a fracture.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced compliant visit. LPA met with Erika Becerra and explained the purpose for todays visit.

The investigation consisted of the following:
On 3/28/25 LPA Herrera conducted the initial 24hr visit and obtained copies of the staff and resident rosters. From 3/28/25-5/27/25 Investigator C.Ferris with the departments Investigations Bureau (IB) conducted an investigation on the above allegation. During todays visit LPA delivered findings.

(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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-20250327161501
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: 06/05/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Staff did not provide adequate supervision resulting in resident sustaining a fracture.
It is alleged that R1 sustained and unwitnessed fall that caused a non-displaced mandibular fracture, due to lack of supervision. IB investigator C.Ferris investigated the above allegation. Investigator reviewed surveillance footage of the incident that clearly showed R1 accidentally fall from their wheelchair and staff responded immediately to assist. R1 does not require assistance while using wheelchair. Investigator C.Ferris interviewed 1 witness (W1) and they stated they saw when R1 accidentally fell on their own and staff responded immediately. Investigator C.Ferris interviewed R1 and it was stated they were going too fast in their wheelchair and fell out. Investigator C.Ferris conducted file review where it was revealed that R1 is able to leave facility unassisted and able to care for their own needs. Per IB investigator C.Ferris this investigation did not provide sufficient evidence to substantiate the above allegation.

Based on statements and interviews conducted with staff, R1 and W1, a review of R1’s file and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
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