197803745-2-9-2023-28-AS-JBAE-CNVTJE-20230209134612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803745
Report Date: 02/09/2023
Date Signed: 02/09/2023 01:46:26 PM

Document Has Been Signed on 02/09/2023 01:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 67	DATE:	02/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Administrator Ana Giron		TIME COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 2/9/2023 at 9:08 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced annual inspection. Upon arriving at the facility LPA met with Assistant Administrator Ericka Becerra and explained the purpose of the visit. Administrator Ana Giron arrived at 9:40 a.m. and finished the visit. The licensee prefers to serve 150 elderly residents. Maximum of 70 non- ambulatory residents may be in the facility. The Facility has a hospice wavier for 5 on file. The facility is a Two-story building in a commercial area. The First floor consists of a tv room, supply closet, Janitor closet, Arts and craft room, administrator office, dining room, kitchen, 1 public bathroom, and 34 bedrooms with private bathrooms. The second floor consists of a library, 2 storage rooms, beauty shop, doctors’ office, 49 bedrooms with private bathrooms. The facility designated room numbers 68-79 as a COVID Wing on the second floor. The basement consists of the laundry room and storage rooms for clean and dirty linens. The facility has an additional basement located outside of the building with extra supplies and residents’ storage. Fire extinguisher observed fully charged throughout the facility. Smoke detectors/ Carbon monoxide located throughout the facility, tested and operational. During today's visit, LPA observed the following: Facility is not operating over capacity or beyond any conditions and limitation on the license. There are no large bodies of water on the property. No firearms on the premises. Facility maintains a comfortable temperature for residents. Bedrooms are equipped with furniture such as bed, chair, nightstands, and overhead lighting. The Licensee ensure grab bars for each toilet, bathtub and shower used by residents. Bathtub or shower have non-skid strips. The hot water temperature measured at 105.0- 119.3 degrees F in various resident bathrooms. Report Continued on 809C

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/09/2023

NARRATIVE

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The signal system is operational. Cleaning supplies are stored and locked in the basement. First aid kit has been inspected and has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, first aid manual are updated and it's available for staff use but inaccessible for residents. A minimum of one week supply of nonperishable foods and 2 days of perishable foods were observed. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. Dishes, cups, and flatware are stored in the kitchen cupboards are in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in the kitchen and only accessible to staff. Refrigerators, stove burners, oven, freezers, washer, and dryers are operable. All outdoor and indoor passageways are kept free of obstruction.

Criminal Record Clearance for all required persons is associated to the license. Staff responsible for direct care and supervision have current first aid training. Facility has a disaster and mass casualty plan. Medications are given per the physician’s directions. There is a signed and dated written order from a physician for every prescription and nonprescription PRN medication. Centrally stored medicines are kept in a safe and locked office. Last Emergency disaster drill conducted 12/12/22.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided to Administrator.

An exit interview was conducted, and a copy of this report provided to Ana Giron.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC809 (FAS) - (06/04)

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