198601838-4-7-2025-28-AS-RORN-DFLNH6-20250410102813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 04/07/2025
Date Signed: 04/07/2025 11:55:10 AM

Unsubstantiated

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
01/24/2025 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250124154506

FACILITY NAME:	DOWNEY RETIREMENT CENTER		FACILITY NUMBER:	198601838
ADMINISTRATOR:	BRANDIE MENDIBLES		FACILITY TYPE:	740
ADDRESS:	11500 DOLAN AVENUE		TELEPHONE:	(562) 869-2416
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	252	CENSUS: 133	DATE:	04/07/2025
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Brandie Mendibles - Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained an unexplained fracture.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to deliver findings on the above allegation. LPA met with Administrator Brandie Mendibles and explained the purpose of today's visit.

The investigation consisted of the following:
During initial visit conducted on 1/27/25 LPA D.Konishi obtained copies of resident/staff rosters. Review of residents files, copies from R1's file were obtained and a health and safety check was conducted including a tour of the facility with no issues or concerns observed.
From 1/27/25 – 3/24/25 investigator J.Canto with the Investigations Branch (IB) investigated the reported allegation.
On todays visit 4/7/25 LPA Herrera delivered findings.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250124154506

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: 04/07/2025

NARRATIVE

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The investigation revealed the following:
Allegation: Resident sustained an unexplained fracture.
It is alleged that R1 sustained a fracture due to lack of care and supervision. This allegation was investigated by Investigations Branch (IB) investigator J. Canto which revealed the following:
During interviews with facility staff members, they stated R1 sustained a witnessed fall on 01/21/2025, R1 was assessed and stated they were not in pain and the POA was contacted and informed of the incident. About 2.5 hours post fall R1 was noted to have discomfort and showed signs of pain. The facility Med-Tech assessed R1, contacted the POA, updated them on R1’s condition, and recommended R1 be transferred to the local hospital for further evaluation. R1 was transferred via ambulance to hospital. The incident was recorded via the facility's closed-circuit monitoring system, J.Canto reviewed and confirmed the incident. Video showed R1 using their wheelchair as a walker (personal preference), enters bedroom, a few seconds later a caregiver’s side profile is seen entering the bedroom in a fast manner, two other caregivers responded, and one of them called for further assistance. J.Canto asked why R1 as not transferred to the hospital immediately after the fall and S1 stated that the fall was witnessed, R1 did not hit their head and initially said they were without pain, once staff were informed of pain R1 was transferred to the hospital where they were diagnosed with a fracture.

Based on statements and interviews conducted with staff/residents, and the information obtained regarding the incident via the staff members being consistent with what was recorded on the video investigator J.Canto found no evidence to corroborate the allegation of neglect and lack of care & supervision by the facility and there was not enough supportive evidence to concur with the reported allegation. 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, and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

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