197803745-8-16-2022-28-AS-RORN-CJ2PWU-20220907114119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:44:37 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
05/04/2022 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220504165358

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: 68	DATE:	08/16/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Erika Becerra; Assistant Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained an unwitnessed fall resulting in injury.
Resident is not being properly supervised while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced subsequent complaint visit regarding the above stated allegations. LPA met with Assistant Administrator Erika Becerra and explained the reason for the visit.

The investigation consisted of the following: during the initial visit conducted on 05/05/22, LPA interviewed the Administrator and obtained copies of Resident & Staff Rosters and conducted a tour of facility including the common areas. LPA also obtained copies from Resident #1 (R1) file such as Resident Appraisal, Physician's Report, Identification and Emergency Information Sheet, Hospital Discharge Paperwork, and Incident Report. During today's visit, LPA interviewed Staff #1 - Staff #3, and Resident #1 - Resident #6.

The investigation revealed the following: in regards to the allegation "resident sustained an unwitnessed fall resulting in injury", it is alleged that R1 had an unwitnessed fall that resulted in a humerus fracture. Interviews conducted with facility staff and R1 confirmed R1 did sustain an unwitnessed fall. Administrator indicated R1 suffered an unwitnessed fall while out in the community on 04/28/22. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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-20220504165358

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: 08/16/2022

NARRATIVE

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When R1 returned to the facility, he notified the facility staff of the fall and complained about pain. He was immediately sent to the hospital and was discharged the same day with no changes in medication or fracture diagnosis. On 05/02/22, R1 notified facility staff that he was still suffering from pain resulting from the unwitnessed fall he had on 04/28/22. Facility once again sent R1 to the hospital and during this visit he was diagnosed with the humerus fracture. R1's Physician Report dated 10/04/21 indicates R1 is able to leave the facility unassisted. Facility staff immediately transported R1 to the hospital upon learning of R1's fall. Although R1 sustained the unwitnessed fall, there is no evidence indicating facility was responsible for the fall or neglectful. Therefore there was insufficient evidence to corroborate with the allegation.

In regards to the allegation "resident is not being properly supervised while in care", it is alleged that facility staff is not properly taking care of R1, as R1 allegedly continues to suffer from falls while at the facility. R1's Physician Report indicates he is Ambulatory. R1 does not have a one-on-one caregiver. Interviews conducted with staff members denied the allegation. Staff members interviewed indicated they provide supervision to all residents in care. Staff members interviewed indicated they will notify management of any witnessed and/or unwitnessed falls or any observed changes in condition of the residents. Residents interviewed denied the allegation. Residents interviewed indicated they feel facility staff provides proper supervision to meet their needs. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files, and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC9099 (FAS) - (06/04)

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