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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 06/06/2025
Date Signed: 06/06/2025 12:59:02 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
06/04/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250604143251
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:
06/06/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Erika Becerra, Assistant AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not providing adequate food service to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator who assisted with the visit. Administrator Ana Giron arrived shortly after. Purpose of the visit was explained.

The investigation consisted of the following: Interviews with Administrator, Staff 1 - Staff 5 ( S1 - S5), interviews with Resident 1- Rsident 8 (R1 - R8), tour the dining room, kitchen, review of facility food supply, and facility menu. Facility Staff and Residents roster were obtained.

Continue 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 06/06/2025
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-20250604143251
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: 06/06/2025
NARRATIVE
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The investigation revealed the following: Regarding the allegation that Staff are not providing adequate food service to residents. It was alleged that facility only provide dinner and R1 has to purchase their own breakfast, lunch and snacks.

Interviewed Administrator and staff denied the allegation. They stated that the facility does provide residents with adequate meals, of good quality three times a day. Also, snacks between meals. Interviews with R1- R8 indicated that the facility serves adequate meals three times a day. They stated that staff also served them snacks. LPA interviewed R1, resident indicated facility did provide adequate food service to residents three times a day. R1 indicated that staff provide snacks between the meals. R1 indicated that they have a good breakfast (French toast, sausage, oatmeal, coffee) and like it. Residents interviewed could not corroborate the allegation. Resident interviews revealed that residents always received three (3) meals a day and snacks between. They stated that they are satisfied with the food service and have no complaints about the food that facility serves. Staff interviews revealed adequate food services were provided to residents and facility serve three meals a day. LPA toured the kitchen and observed food supply was adequate. LPA also obtained a copy of the facility menu for review. LPA toured the dining area during lunch time and observed the meal that was served to the residents. They were served soup, potato salad, sandwiches, juice, fruit cocktails.

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.

No deficiencies cited. Copy of report provided to Ana Giron.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

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

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