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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 04/05/2022
Date Signed: 04/05/2022 02:23:36 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
06/12/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200612152308
FACILITY NAME:DOWNEY RETIREMENT CENTERFACILITY NUMBER:
198601838
ADMINISTRATOR:MARY MIMS-BURRISFACILITY TYPE:
740
ADDRESS:11500 DOLAN AVENUETELEPHONE:
(562) 869-2416
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:252CENSUS: 103DATE:
04/05/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Michele GoodneyTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Staff are not associated to the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with Administrator, Michele Goodney and explained the reason for the visit. The initial complaint visit was conducted by LPA Rivas on 6/18/20. LPA Rivas conducted a subsequent visit on 6/23/20.

The investigation consisted of the following: LPA Rivas conducted interviews with 10 residents and 2 staff. LPA Vasallo conducted interviews with 10 residents and 5 staff including Med Techs and Administrator. LPA reviewed 7 residents medications and medication records.

The investigation revealed the following: It's alleged staff do not have their fingerprints associated to the facility. LPA obtained a staff roster from June 2020. LPA observed Staff #1's (S1) name on the roster. LPA researched S1's fingerprints and it revealed that S1's fingerprints were never associated to the facility. S1 was hired on 10/4/19. S1's file has a fingerprint transfer request on file dated 6/18/20, which is 8 months after S1 was hired.
Continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
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 5
Control Number 28-AS-20200612152308
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: 04/05/2022
NARRATIVE
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Interviews conducted with staff also confirmed S1 was an employee of the facility. S1's fingerprint transfer request was submitted 8 months after being hired and S1's fingerprints were never associated to the facility. Based on the information obtained, the allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is 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 held with Administrator. A copy of the report and appeal rights will be provided via email due to printer issues.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20200612152308
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: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2022
Section Cited
CCR
87411(g)(2)
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Personnel Requirements - General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Facility will certify all staff will have a fingerprint clearance and will be associated to the facility prior to employment or initial presence in the facility. It should be noted, S1 no longer works for the facility as of July 2020.
Civil penalties were issued in the amount of $500.
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This deficiency was evidenced by the following:
Records reviewed S1 was hired on 10/4/19. Facility did not request fingerprint transfer until 6/18/20. S1's fingerprints were never associated to this facility. Staff also confirmed S1 was a staff member at the facility.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/12/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200612152308

FACILITY NAME:DOWNEY RETIREMENT CENTERFACILITY NUMBER:
198601838
ADMINISTRATOR:MARY MIMS-BURRISFACILITY TYPE:
740
ADDRESS:11500 DOLAN AVENUETELEPHONE:
(562) 869-2416
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:252CENSUS: 103DATE:
04/05/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Michele GoodneyTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Staff are not following Dr. orders.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with Administrator, Michele Goodney and explained the reason for the visit. The initial complaint visit was conducted by LPA Rivas on 6/18/20. LPA Rivas conducted a subsequent visit on 6/23/20.

The investigation consisted of the following: LPA Rivas conducted interviews with 10 residents and 2 staff. LPA Vasallo conducted interviews with 10 residents and 5 staff including Med Techs and Administrator. LPA reviewed 7 residents medications and medication records.

The investigation revealed the following: It's alleged staff are giving 8 pm medications to residents at 5 pm. It's also alleged residents receive pain medication without physician's orders. A total of 20 residents were interviewed. Residents reported having no issues with the time they get their medications. Residents who have 8 pm medications indicated they do receive those medications on time. Residents deny receiving pain medication without physician's orders. Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
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 5
Control Number 28-AS-20200612152308
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: 04/05/2022
NARRATIVE
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Staff interviewed deny the allegation. Staff indicated 8 pm medication will only start as early as 7:30 pm, but never at 5 pm. Medication records reviewed confirmed residents taking pain medication have a physician's order. Medications were reviewed and there were no errors found. Based on the information obtained, the allegation is unsubstantiated.

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.

Exit interview held with Administrator. A copy of the report will be emailed due to printer issues.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5