198601838-6-28-2025-28-AS-DSIS-DJ6VDD-20250701162034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 06/28/2025
Date Signed: 06/28/2025 01:23:27 PM

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
06/18/2025 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250618163057

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: 132	DATE:	06/28/2025
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Jorge Pena - LVN		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident suffered a fall due to staff neglect/lack of care and supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to deliver findings for the above allegation. LPA met with LVN Jorge Pena and explained the purpose of today's visit.

The investigation consisted of the following:

On 6/26/25 LPA obtained copies of staff/resident rosters, toured facility, obtained copies of Special Incident Reports (SIR's) and interviewed 5 staff and 13 residents.
On 6/27/25 LPA obtained documents via email within R1's file that are relevant to investigation.
On 6/28/25 LPA delivered findings for above allegation.

(Continued on LIC9099-C)

Substantiated

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: 06/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2025

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 4

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
06/18/2025 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250618163057

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: 132	DATE:	06/28/2025
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Jorge Pena - LVN		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility staff failed assist a resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to deliver findings for the above allegation. LPA met with Jorge Pena - LVN and explained the purpose of today's visit.

The investigation consisted of the following:
On 6/26/25 LPA obtained copies of staff/resident rosters, toured facility, obtained copies of Special Incident Reports (SIR's) and interviewed 5 staff and 13 residents.
On 6/27/25 LPA obtained documents via email within R1's file that are relevant to investigation.
On 6/28/25 LPA delivered findings for above allegation.

(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: 06/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2025

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20250618163057

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: 06/28/2025

NARRATIVE

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The investigation revealed the following:
Allegation: Facility staff failed assist a resident in a timely manner.
It is alleged that on October 18, 2023 at 12am, R1 fell out of their wheelchair several times and staff did not respond when called. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation, staff stated that during this time R1’s room was located on the 1^st floor of the Assisted Living area of facility and this is where residents who require more assistance and monitoring are places as it is closer to the med-tech, LVN and management personnel. Staff stated R1 was noted as a fall risk resident and was checked on every 30-45 minutes, as opposed to every 1-2 hours that other residents are checked on. Additionally, staff stated that when a resident suffers a fall immediate action is taken, caregiver calls for nurse to assess while staying with resident, nurse will assess resident to ensure it is safe to staff to assist with lifting resident, and proper care is provided from there. LPA interviewed 13 residents and 12 out of 13 residents denied the above allegation and stated that staff arrive promptly when they need assistance. 6 of the 13 resident stated they have suffered a fall at the facility and staff assisted them right away and were taken to the hospital for evaluation and treatment.

Based on statements and interviews conducted with staff, tour of facility, and resident record review, 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: 06/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 28-AS-20250618163057

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: 06/28/2025

NARRATIVE

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The investigation revealed the following:
Allegation: Resident suffered a fall due to staff neglect/lack of care and supervision.
It is alleged that while R1 was being assisted with a shower staff walked away resulting in R1 sustaining a fall with injuries that have caused R1 to be bedridden. This incident was investigated by LPA Herrera on 5/31/24 after facility self-reported and submitted a Special Incident Report (SIR) that explained staff that was assisting R1 with a shower, left R1 unattended while assisting with the shower, R1 then experienced 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. Staff has since then been terminated from employment at facility and Administrator retrained all staff in assisting Residents with Activities of Daily Living (ADL's) and re-retrained staff on proper procedures to take when a backup caregiver assistance is needed. There was a citation previously issued for this incident under regulation number 87468.2(a)(4). The plan of correction was submitted to LPA by the due date and has since been cleared. No citation will be issued on todays visit since this was previously addressed, however, since this incident did occur the above allegation is Substantiated.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Exit interview held, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2025

LIC9099 (FAS) - (06/04)

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