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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601838
Report Date: 05/31/2024
Date Signed: 05/31/2024 11:07:24 AM


Document Has Been Signed on 05/31/2024 11:07 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:BRANDIE MENDIBLESFACILITY TYPE:
740
ADDRESS:11500 DOLAN AVENUETELEPHONE:
(562) 869-2416
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:252CENSUS: 132DATE:
05/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Brandie Mendibles - AdministratorTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera made an unannounced Case Management visit to the facility. LPA met with Administrator Brandie Mendibles and explained the reason for the visit.

The purpose of the visit is to conduct a Health and Safety Check in regards to a Special Incident Report (SIR) that was received on 5/21/24, regarding an incident in which S1 left R1 unattended while assisting with showering, R1 had an unwitnessed fall and suffered injuries during the time they were left unattended, which resulted in R1 being sent to the hospital and receiving staples on a laceration on their head.

During todays visit LPA obtained copies of the following from Resident #1 (R1) file: Physician Reports (2024/2023), most current appraisal needs and service plan and hospital paperwork/discharge paperwork from this incident that was dated 5/18/2024.

After interviews with both Administrator and S1 it was confirmed that the above incident did occur, after file review it was revealed that R1 needs max assistance with 1 person while showering.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during todays visit is documented on the 809D.

Exit interview held and a copy of the report along with appeal rights were provided to Brandie Mendibles.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/31/2024 11:07 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: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2024
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This was not met as evidence by:
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Licensee/Administrator to retrain all staff in assisting Residents with Activities of Daily Living (ADL's) and training on proper procedures to take when a back up caregiver assistance is needed.
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The Department received a Special Incident Report on 5/21/24 stating that on 5/18/24 R1 sustained injuries and was sent to the hospital after being experiencing a unwitnessed fall when S1 left R1 unattended during a shower for approximately 5 minutes. Interviews with Administrator and S1 confirmed this story as well as record review of both S1 and R1.
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Copy ot the training materials along with the date trainings will be conducted, must be emailed to LPA by 6/1/21.
tena.herrera@dss.ca.gov

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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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