197803745-1-22-2026-28-AS-FFIS-DSG23Y-20260323170307

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 01/22/2026
Date Signed: 01/22/2026 04:55:04 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/29/2025 and conducted by Evaluator Elena Mallett

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251029103225

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: 89	DATE:	01/22/2026
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Administrator-Ana Giron		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Licensee did not ensure that facility was in good repair.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Elena Mallett, Jewel Baptiste along with Licensing Program Manager (LPM) Fernando Fierros conducted and unannounced subsequent visit to the facility and met with Assistant Adminstrator Erika Becerra and the reason for the visit was discussed. Later on, Administrator, Ana Giron joined the visit. Due to additional information obtained the findings are being changed to Substantiated.

On 11/04/2025, LPA Sanjay Vaid conducted the intital visit and met with Assistant Administrator Erika Becerra and Administrator Ana Giron. During the visit, LPA Vaid requested and obtained the resident roster, staff roster. Residents #1-#3( R1-R3), face sheet, Physcian's Report, Preplacement Report. Administrator Giron and LPA Vaid toured the facility. LPA Vaid interviews Administrator Giron and four(4) staff and eight(8) residents, including Resident #1( R1).

Report continued on LIC 9099-C

Substantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Elena Mallett
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

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-20251029103225

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: COUNTRY INN OF DOWNEY	FACILITY NUMBER: 197803745
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/06/2026 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility will submit proof of correction via a photo to Licensing by POC due date.
	8 9 10 11 12 13 14	As evidenced by observation and record reivew Resident 1's room contained a broken window of which Administrator was aware of since early November 2025 and has not been repaired, which poses a potential health and safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Elena Mallett
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20251029103225

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: COUNTRY INN OF DOWNEY	FACILITY NUMBER: 197803745
	VISIT DATE: 01/22/2026

NARRATIVE

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On today's visit LPAs Mallett and Baptiste toured the physical plant along with Assistant Administrator Becerra, including a tour or Room #7, common area and outside courtyard. LPAs did not observe any health and safety concerns. LPAs interviewed Administrator Giron, four (4) staff and two (2) additional residents. LPAs obtained staff and residents' roster, maintenance records, vendor estimates for repair and incident report dated 11/23/23 regarding Resident #1's behaviors.

It is alleged that the facility is in disrepair, a resident's room has a broken window and broken floor tiles which the facility has not repaired in about six months. Interviews with seven staff revealed that one of seven staff was aware of Room # 7 having a cracked window around November 2025. One of seven staff reported of being aware of the cracked window in Room #7 for about a month. Five out of seven staff were not aware of the facility being in disrepair. Interviews with nine of ten residents revealed that the facility is in good repair and if repairs are reported to staff, repairs are made within 24 hours. One out of ten residents interviewed reported that a resident's room has had cracks in the window for several years, and staff replaced a few broken tiles, however the tiles are mismatching. Administrator stated the facility has obtained two estimates to repair the cracked window in Room #7. The Administrator stated they observed the cracked window in early November 2025, and the window has not been repaired. However the cracked window does not pose an immediate danger to the residents. On today's visit, LPAs Mallett and Baptiste observed that in Room #7, the exterior window pane on the lower right side contained several cracks that traveled through out the window.

Based on LPAs observations, interviews with staff and residents, review of pertinent documents, the preponderance standard of evidence has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22 are being cited on the attached LIC 9099-D.

Exit interview was conducted with Administrator Giron and a copy of the Licensing Report along with Appeal Rights were given at the time of the visit and were discussed.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Elena Mallett
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

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