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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803745
Report Date: 07/17/2026
Date Signed: 07/17/2026 11:15:50 AM

Document Has Been Signed on 07/17/2026 11:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 DOWNEYFACILITY NUMBER:
197803745
ADMINISTRATOR/
DIRECTOR:		ANA YESENIA GIRONFACILITY TYPE:
740
ADDRESS:11111 MYRTLE ST.TELEPHONE:
(562) 869-2401
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 150CENSUS: 79DATE:
07/17/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator GironTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit- Deficiencies on 07/17/2026. LPA Ramirez met with Administrator Giron and explained the purpose of the visit. During today’s visit LPA Ramirez discussed with Administrator Ana Giron discrepancies identified between staff#4 (S4) interview statements and the video evidence obtained by LPA on 05/19/2026. Interview statements made by S4 on 05/19/2026, revealed that no water leaked onto R1’s bathroom floor, facility hallway and that R1’s bathroom sink was only in disrepair for one (1) day. Video evidence obtained by LPA Ramirez on 05/19/2026, revealed that R1’s bathroom sink was in disrepair for at least five (5) days from 05/09/2026 through 05/14/2026 and water was observed throughout R1’s bathroom floor on 05/14/2026. Interviews with five (5) out of six (6) residents revealed they remembered on or around 05/07/2026, R1 yelling to “shut off the water!” and when residents opened their bedroom door, they observed water rapidly flowing out of R1’s room and into the facility hallway. Interview with R1 revealed that for eight (8) days R1’s bathroom sink was in disrepair and R1 was unable to use their bathroom sink for grooming needs and was not offered to be relocated to another room while repairs were pending. Interview with Administrator Giron corroborated that R1 was not relocated to another room while R1’s sink was being repaired. Administrator Giron and S4 both denied that R1’s bathroom sink was in disrepair for more than one (1) day and that water flooded R1’s bathroom or facility hallway.

Based on interview statements gathered and video evidence obtained, LPA Ramirez issued one (1) deficiency for staff making false or misleading statements regarding the facility and one (1) deficiency for violation of R1’s personal rights. Two (2) deficiencies for violation of California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 809-D.

Fernando Fierros
Kimberly Ramirez
DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/17/2026 11:15 AM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/17/2026 at 10:03 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2026
Section Cited
CCR
87468.1(a)

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Personal Rights of Residents in Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to draft a plan that lists what steps the facility will take to provide safe, healthful and comfortable accommodations for residents while repairs are being made in resident rooms. Plan must be emailed to LPA Ramirez
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R1 was not relocated or offered to be moved into another room until repairs to their bathroom sink was completed. This poses a potential risk to the health, safety, or personal rights of persons in care.
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Type B
07/25/2026
Section Cited
CCR87207

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False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement was not met as evidenced by:
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Licensee will provide staff retraining on this regulation and provide LPA with proof of all staff attendance.
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Staff S4 made false and misleading statements when interviewed by LPA Ramirez
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2026


LIC809 (FAS) - (06/04)
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