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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601838
Report Date: 07/07/2023
Date Signed: 07/07/2023 11:06:29 AM


Document Has Been Signed on 07/07/2023 11:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:DOWNEY RETIREMENT CENTERFACILITY NUMBER:
198601838
ADMINISTRATOR:MICHELE R GOODNEYFACILITY TYPE:
740
ADDRESS:11500 DOLAN AVENUETELEPHONE:
(562) 869-2416
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:252CENSUS: 124DATE:
07/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Brandie Mendibles - Administrator TIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced case management visit at the facility due to observed deficiencies during a complaint investigation visit. LPA met with Brandie Mendibles Administrator and explained the reason for the visit.

On 5/15/23 LPA Flores and Maldonado conducted a tour of the facility's kitchen. During the tour LPAs observed the following:
Egg whites with expiration date: 4/11/22.
Gallon of vinegar with best by date: 2/19/22.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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Document Has Been Signed on 07/07/2023 11:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
87555(a)

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87555 General Food Service Requirements: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents...

This requirement is not met as evidence by:
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Administrator will provide in-service training to kitchen staff regarding quality of food, storing, disposing, shelf life of food items, and will submit a copy of in-service training with topic, duration of training, and sign-in log by POC due date 7/14/23.
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Based on observation Licensee did not ensure staff properly stored and disposed of expired/best by food items wich poses a potential personal right, health, or safey risk to the persons in care.
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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