197803745-8-22-2022-28-AS-MVAO-CJAPN8-20220915112732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 08/22/2022
Date Signed: 08/22/2022 03:35:56 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
12/31/2020 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201231101726

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:	DATE:	08/22/2022
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Ana Giron- Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff mishandling resident's money.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made a subsequent visit at the facility regarding the above-mentioned allegation and to deliver findings. LPA Maldonado met with administrator Ana Giron and explained the purpose of the visit.

On 01/08/21, LPA Kruz Long made an initial virtual complaint visit due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures. During the visit, LPA Long requested a copy of the Resident/Staff, Resident #1's signed payment agreement and interviewed Staff #1.

During the visit conducted on 08/17/22, LPA Maldonado requested a copy of resident and staff roster, and the following documents for Residents# 1- #6 (R1-R6): Facesheet, Phsycian's Report, Appraisal, payment agreement for residents who receive personal and incidental (P&I) funds, and Record of Resident's Safefguarded Cash Resources for 2020. LPA also conducted interviews with Staff# 1-#4 (S1-S4) and R2-R6.
(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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-20201231101726

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: 08/22/2022

NARRATIVE

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LPA Maldonado conducted a telephone interview with R1 due to R1 no longer residing at the facility.

Allegation: Staff mishandling resident's money.
During confidential interviews conducted with R1-R6, (6) of (6) residents stated that the facility handled their Personal and Incidental (P&I) funds. After review of records for R1-R6, it was discovered that (4) of (6) residents qualified to receive a stimulus payment and all received their money accordingly- payment acknowledgement agreements were provided, signed and dated, by respective residents. During interviews conducted with S1-S4, all residents who received stimulus payments and who currently receive P&I funds have been issued their funds accordingly, as requested. (5) of (6) residents interviewed have no knowledge or concerns of staff mishandling their money.

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 allegation is UNSUBSTANTIATED.

No deficiencies were observed or cited during the visit.

An exit interview was conducted with administrator Ana Giron and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC9099 (FAS) - (06/04)

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