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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 07/17/2026
Date Signed: 07/17/2026 11:18:46 AM

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
05/11/2026 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260511092326
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: 79DATE:
07/17/2026
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Administrator Ana GironTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not ensure resident's room was not in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 07/17/2026 regarding the above allegation. On 05/19/2026, LPA Ramirez conducted an initial complaint investigation visit and a need for further investigation was documented. During today’s visit LPA Ramirez was greeted by Administrator Ana Giron and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 5 interviews (S1 - S5), Resident#1-6 interviews (R1 - R6), and physical plant tour.

See 9099-C for continued narrative.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20260511092326
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: 07/17/2026
NARRATIVE
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The investigation revealed the following: regarding the allegation “Staff did not ensure resident's room was not in disrepair.” It is alleged that staff did not repair a leak in R1’s bathroom sink for eight (8) days. Five (5) out of six (6) residents interviewed corroborated this allegation. Resident interviews revealed that on or around 05/07/2026, R1’s bathroom sink began to leak. Staff was alerted about the leak and staff#4 (S4) attempted to repair the leak, however, when S4 turned the water back on, the pipe busted water all over R1’s bathroom floor and into the facility hallway floor. During resident interviews, LPA observed and obtained video evidence that documented on at least five (5) days from 05/09/2026 through 05/14/2026, R1’s bathroom sink was in disrepair, and water was observed throughout the bathroom floor on 05/14/2026. Five (5) out of the five (5) staff interviewed denied this allegation. Interview with S4 revealed that R1’s bathroom sink was leaking on 05/14/2026 and was repaired the same day later in the evening. S4 revealed that R1’s bathroom sink leak never leaked onto R1’s bathroom floor or in the facility hallway. S4 revealed that R1’s bathroom sink was in disrepair for one (1) day only and was repaired by a plumbing company. Interview with witness#1 (W1) revealed they were the plumbing company that was dispatched to fix the leak in R1’s room and other plumbing issues on 05/14/2026. W1 revealed that service notes indicated water was observed in R1’s bathroom floor. During record review, LPA observed facility maintenance report for May 2026. This log recorded one entry; which indicated on 05/14/2026 R1’s sink needed a repair.

Based on LPAs observations and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Giron and a copy of this report, 9099-D and appeals rights was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260511092326
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: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2026
Section Cited
CCR
87303(a)
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Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services for the safety and well-being of residents, employees and visitors.
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Administrator agreed to draft a plan on steps the facility will take to ensure complaince with regulation 87303(a).
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This requirement was not met as evidenced by: R1's bathroom sink was in disrepair and was not repaired for 8 days. This poses a potential risk to the health, safety, or personal rights of persons in care.
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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.
SUPERVISOR'S NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3