198601838-8-18-2021-28-AS-FFIS-C6E2WD-20210830174521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 08/18/2021
Date Signed: 08/18/2021 01:46:20 PM

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
08/13/2021 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210813142533

FACILITY NAME:	DOWNEY RETIREMENT CENTER		FACILITY NUMBER:	198601838
ADMINISTRATOR:	MICHELE R GOODNEY		FACILITY TYPE:	740
ADDRESS:	11500 DOLAN AVENUE		TELEPHONE:	(562) 869-2416
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	252	CENSUS: 92	DATE:	08/18/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Michele Goodney (Administrator)		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility water pump is in disrepair.
Facility does not have hot water.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Michele Goodney (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff schedule and Resident roster and water pump order receipt. LPA interviewed Staff #1 and Staff #2 in the office between 10:00 am to 10:26 am, interviewed Resident #1,#2,#3 and #4 in the Family room between 10:40 am to 11:25 am. LPA also measured the water temperature in Room #221, #266, #227 and #273 between 12:10 pm to 12:30 pm.

In regards to the allegation: Facility water pump is in disrepair. LPA's record review and interviews indicate that the water pump was broken on 08/04/21 and a new water pump was not ordered until 08/11/21. Water pump order arrived on 08/16/21 and repair was completed the same day.

Continue to LIC9099C......

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

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-20210813142533

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: DOWNEY RETIREMENT CENTER	FACILITY NUMBER: 198601838
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/25/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall immediately repair water pump and provide proof to the department by the POC date.
	8 9 10 11 12 13 14	Water pump was broken on 08/04/21 and a new water pump was not ordered until 08/11/21. Water pump order arrived on 08/16/21 and repair was completed the same day.	8 9 10 11 12 13 14	*Note: Water pump repaired on 08/16/21.**
Type B 08/25/2021 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	87303(e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).	1 2 3 4 5 6 7	Licensee shall immediately repair water pump and ensure hot water temperature measures between 105 degree F and 120 degree F throughout the entire facility.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Interviews with 4 of 4 Residents indicate facility lacked running hot water on the 2nd floor of the facility from the time the water pump broke until the repair was completed.	8 9 10 11 12 13 14	Note: LPA tested water temperature in various rooms which measures within Title 22 guidelines.*

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	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210813142533

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: DOWNEY RETIREMENT CENTER	FACILITY NUMBER: 198601838
	VISIT DATE: 08/18/2021

NARRATIVE

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In regards to the allegation: Facility does not have hot water. Interviews with 4 of 4 Residents indicate facility lacked running hot water on the 2nd floor of the facility from the time the water pump broke until the repair was completed.

Based on LPA's record review and interviews, investigation revealed 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 being cited on the attached LIC 9099D.

Exit interview conducted with Michele Goodney and a copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC9099 (FAS) - (06/04)

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