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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601838
Report Date: 01/27/2025
Date Signed: 01/27/2025 01:52:09 PM

Document Has Been Signed on 01/27/2025 01:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DOWNEY RETIREMENT CENTERFACILITY NUMBER:
198601838
ADMINISTRATOR/
DIRECTOR:		BRANDIE MENDIBLESFACILITY TYPE:
740
ADDRESS:11500 DOLAN AVENUETELEPHONE:
(562) 869-2416
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 252TOTAL ENROLLED CHILDREN: 0CENSUS: 134DATE:
01/27/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Brandie Mendibles, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted a complaint visit at 11:25am. During the course of the investigation related to Complaint Control Number: 28-AS-20250124154506, LPA observed in room 109, resident #2 (R2) has an oxygen tank in the room, and a "No Smoking-Oxygen in Use" sign was not posted outside resident room door and not at appropriate areas.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided to the Administrator, Brandie Mendibles.

David SicairosTELEPHONE: (323) 981-3982
Daniel KonishiTELEPHONE: 323-981-3978
DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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 01/27/2025 01:52 PM - 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
MONTEREY PARK ASC, 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: 01/27/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid. (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 01/28/2025
Plan of Correction
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Administrator shall ensure that a No Smoking-Oxygen in Use sign is posted on resident door or appropriate areas when oxygen tanks are used inside the room.

Submit picture proof that the signs are posted.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
David SicairosTELEPHONE: (323) 981-3982
Daniel KonishiTELEPHONE: 323-981-3978

DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025

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