198601838-1-19-2023-28-AS-RORN-CRNQRL-20230509122408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 01/19/2023
Date Signed: 01/19/2023 03:46:30 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
01/13/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230113163211

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: 118	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Brandie Mendibles		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to facility for the purpose of investigating the allegation above. LPA met with Administrator Brandie Mendibles and explained the reason for the visit.
The purpose of the visit is to investigate the above allegation.
LPA conducted interview with Administrator at 1:45 P.M.
LPA obtained and reviewed staff and resident rosters.
Interview was conducted with Staff S 1 at 2:00 P.M. and Staff S 2 at 2:20 P.M.
Interviews were conducted with Resident's R1 - R 7 from 2:25 P.M. to 3:10 P.M. R 1 and R 2 were limited in their response to questioning.
LPA reviewed R 1's file and Physician's Report, Emergency ID page and Special Incident Report were submitted.
In regards to the allegation Resident sustained unexplained injuries while in care, based on interviews conducted and information gathered staff stated that R1 had fallen and hit her eyebrow bone on another residents wheelchair in the dining room. Staff stated that first aid was immediately applied and 911 was

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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-20230113163211

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: 01/19/2023

NARRATIVE

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immediately called.
Special Incident Report (SIR) was submitted to licensing describing the incident that had occurred on 01/01/2023.
Resident was found to have a hematoma above right eyebrow. Blood pressure and temperature checked and R1 was feeling nauseous and dizzy . 911 called.
R 1 stated she had fallen and staff helped, but could not remember where it occurred.
R3- R7 stated that they had not witnessed any falls. Stated that staff are professional and compassionate and are attentive constantly in the dining room and tend to all their needs,.

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.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

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