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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 07/07/2023
Date Signed: 07/07/2023 11:02:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/10/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220510113455
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
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Brandie Mendibles - Administrator TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff misplaced resident’s medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s)(LPA) Mary Flores conducted a subsequent investigation visit at the facility to deliver findings on the above allegation(s). LPA met with Brandie Mendibles Administrator and explained the reason for the visit.

The investigation consisted of the following: On 5/15/22 LPA Flores and Maldonado conducted an initial visit investigation. LPAs tour facility's commercial kitchen and 10 resident rooms. LPAs requested a copy of resident roster and staff roster, 4 weeks of menu, invoices for food deliveries for a month, staff's warning notice, dining service director's application, incident reports for residents that have fallen in the past month. LPAs conducted medication review for 11 residents. On 6/7/23 LPA Flores interview 5 staff and requested a copy of cooks’ food handler certificate. On 6/19/23 LPA interviewed 8 residents over the phone. On 6/23/23 LPA interviewed 1 resident over the phone. On 7/7/23 LPA interview one additional resident.

(CONTINUED LIC 9099C)
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 28-AS-20220510113455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/07/2023
NARRATIVE
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The investigation revealed the following: Regarding allegation: Staff misplaced resident’s medication. It is alleged resident's medication (Norco) was misplaced. On 5/15/22 previous facility Administrator stated staff #2 (S2) had been given a warning as a result for leaving medication (Norco) on top of a file cabinet at the reception. S2 did not store the medication over night per facility’s policy, after it was delivered to the facility. Interviews with 6 staff revealed no concerns of medication being misplaced have been brought up by residents or other staff. Interviews with residents revealed, 10 out of 10 residents did not have concerns about medication being misplaced by staff. Documents review revealed an employee warning notice was given to staff #2 , who upon receiving medications (Norco) on 4/23/22 left the medication on top of filing cabinet and did not properly stored the medication.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 is being cited.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20220510113455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
07/08/2023
Section Cited
CCR
87465(h)(2)
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87465 Incidental, Medical, and Dental: (h) The following requirements shall apply:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision.
This requirement is not met as evidence by:
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Administrator will scheduel in-service by 7/8/23, will provide in-service training to Medication technicians and will submit a copy of in-service training with topic, duration of training, and sign-in log to the department by 7/14/23.
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Based on document review staff did not properly stored medication which poses an immediate risk to the safety, health, or personal rights 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
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/10/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220510113455

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
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Brandie Mendibles - Administrator TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff does not provide adequate food service for resident.
Resident fell while in care.
Staff did not properly prepare food in result of food poisoning.
Staff does not meet residents’ dietary needs.
Facility phone is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s)(LPA) Mary Flores conducted a subsequent investigation visit at the facility to deliver findings for the above allegation(s). LPA met with Brandie Mendibles Administrator and explained the reason for the visit.

The investigation consisted of the following: On 5/15/22 LPA Flores and Maldonado conducted an initial visit investigation. LPAs tour facility's commercial kitchen and 10 resident rooms. LPAs requested a copy of resident roster and staff roster, 4 weeks of menu, invoices for food deliveries for a month, staff's warning notice, dining service director's application, incident reports for residents that have fallen in the past month. LPAs conducted medication review for 11 residents. On 6/7/23 LPA Flores interview 5 staff and requested a copy of cooks’ food handler certificate. On 6/19/23 LPA interviewed 8 residents over the phone. On 6/23/23 LPA interviewed 1 resident over the phone. On 7/7/23 LPA interview an additional resident.

(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20220510113455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/07/2023
NARRATIVE
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The investigation revealed the following: Regarding allegation: Resident fell while in care. It is alleged resident had a fall on the floor two to three months ago at 2:00am and was not assisted. Interviews with residents revealed, 9 out of 10 residents stated facility staff is quick to assist residents when sustained a fall and/or assist to prevent falls. 1 out of 10 residents stated staff take at least 45 minutes to respond when a resident needs assistance during a fall. Interviews with staff revealed, 6 out of 6 staff stated staff respond quickly when resident’s report a fall. Document review revealed, incident reports between February and May 2023 a total of 9 resident falls in which staff assisted with either helping resident during fall, body checks, and/or medication.
Based on interviews conducted and document review, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not properly prepare food resulting in food poisoning and Staff does not provide adequate food service for resident. It is alleged the food at the facility are getting residents ill and food is either under cook or over cook. Interviews with residents revealed, 6 out of 10 residents interview stated to not have been sick due to food eaten at the facility and facility has not serve under cook or over cook meals. 4 out of 10 residents stated to have felt sick after consuming food at the facility. However, they did not go out to the hospital or reported their symptoms to staff. 2 out of the 3 residents stated food has either been under cook or over cook when served. Documents review revealed, there are no incident reports noting residents send out to the hospital due to food poisoning or related to food related illness. No physician’s notes for treating residents for food poisoning.
Based on interviews conducted and document review, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff does not meet resident’s dietary needs. It is alleged resident’s food is not pureed completely. 8 out of 10 residents stated facility staff follow dietary needs for residents. 2 out of 10 residents stated dietary needs don’t seem to be followed by facility staff. Interviews with staff revealed, 6 staff stated to follow physician’s recommendation for dietary needs and when pureing food, the items are blended to the recommended consistency.
(CONTINUED ON LIC 9099C)
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
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 28-AS-20220510113455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/07/2023
NARRATIVE
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During facility’s tour on 5/18/22 LPAs observed puree meals prepared for at least 4 residents. Each puree meal was prepared according to the needs of the residents per staff. LPA observed some pureed meals consistency varied from broth like to thicker items.

Based on interviews, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Facility phone is in disrepair. It is alleged resident waited 45 minutes prior to receiving assistance due to facility phone being in disrepair. Interviews with residents revealed 8 out of 10 residents stated the facility’s phone in their room works properly, connects to the main lobby, and receptionist answers their calls. 2 out of 10 residents stated the phone does not work and when they have attempted to contact staff in the main lobby, they waited up to 45 minutes. Interviews with 6 staff revealed each room has a telephone that directly connects with the main lobby. Receptionist responds calls as they come in. During facility’s tour LPA tested each residents’ phone that connects with the main lobby and each facility phone was in working condition.

Based on interviews, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with administrator and a copy of this report was 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
LIC9099 (FAS) - (06/04)
Page: 5 of 6