197803745-6-16-2022-28-AS-LHIS-CGVV6M-20220801160947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 06/16/2022
Date Signed: 06/16/2022 02:14:56 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
06/09/2022 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20220609092432

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: 67	DATE:	06/16/2022
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Assistant administrator, Erika Becerra		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is not meeting resident's dietary needs.
Facility food is of poor quality.
Facility does not serve nutritious meals.

INVESTIGATION FINDINGS:

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On 6/16/22 at 9:38 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Erika Becerra (Assistant Administrator) and explained the purpose of the visit. Anna Giron (Administrator) joined the visit at 10:30 a.m.

During today’s visit LPA and assistant administrator toured the Kitchen, dining room and inspected the food supply. LPA obtained resident/ staff roster, menu (1 month), grocery list (1 month) with attached food purchase receipt, dietitian notes, resident assessment dated 2/18/2022 and admission agreement. LPA also interviewed: administrator and a total of two (2) staff who shall be referred to as S1 and S2. LPA interviewed a total of 7 current residents who shall be referred to as: R1 through R7. LPA conducted file review for 2 residents and 1 staff.

Report continued on 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

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-20220609092432

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: 06/16/2022

NARRATIVE

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The investigation reveals the following: In regard to " Facility is not meeting resident's dietary needs.", it is alleged that the facility does not meet the dietary needs of R1 as prescribed by the doctor. During the visit LPA toured the facility and observed a list of diabetic clients and facility menu posted in the kitchen and dining room. Administrator confirmed dietitian inspect the kitchen and food every two months. 2/2 staff interviews confirmed they check the list and provide diabetic residents alternative meals. 7/7 residents confirmed facility has a diabetic menu and they can request alternative meals if they do not like the current menu. R1 file review revealed R1 is not on a special diet.

The investigation reveals the following: In regard to " Facility food is of poor quality", it is alleged that the facility does not serve good quality food. 7/7 residents confirmed the facility has good quality food. LPA toured the facility during lunch and did not observe poor quality food. 2/2 staff confirmed that the quality of food is good because residents always ask for more.

The investigation reveals the following: In regard to " Facility does not serve nutritious meals.", it is alleged that the facility does not serve nutritious meals. During the visit LPA observed facility food supply and confirmed enough veggies, fruits, grains and proteins. Review of dietitian notes dated 4/13/2022 confirmed facility menu meets the needs of resident population. 2/2 staff interviews confirmed residents are served nutritious foods. 6/7 residents confirmed receiving veggies, fruits and starches every day.

Based on LPA's observation, interviews and file review the investigation revealed: 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 allegations are UNSUBSTANTIATED. Exit interview conducted with Erika Becerra and a copy of this record provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC9099 (FAS) - (06/04)

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