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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 09/08/2022
Date Signed: 09/08/2022 01:57:47 PM

Unsubstantiated


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
11/16/2020 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201116165416
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: 105DATE:
09/08/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Michele Goodney- AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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9
Resident is unkempt.
Resident is ridiculed by staff.
Resident was hit by unknown person.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unnanounced subsequent complaint visit to the facility regarding the above mentioned allegations. LPA Maldonado met with adminstrator Michele Goodney and explained the purpose of the visit.

On 08/16/22, LPA Maldonado made an initial visit and interviewed the Administrator and Staff# 2-#4, (S2-S4). No resident interviews were conducted due to a COVID outbreak in the facility. LPA also requested staff and resident rosters, as well as the following documents from Resident #1's (R1) file: Physicians report, Needs and Services Plan, Resident Appraisal, Identification and Emergency Information, and incident reports for November 2020, and any police reports available.

During today's visit, LPA Maldonado requested a copy of the staff and resident rosters, and interviewed Residents #2- #10 (R2-R10). A telephone interview was conducted with R1 due to resident no longer residing at the facility. (Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
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 2
Control Number 28-AS-20201116165416
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: 09/08/2022
NARRATIVE
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Regarding allegation: Resident is unkempt.
In interviews conducted with R1, R1 stated that assistance with Activities of Daily Living (ADL's) were not needed during R1's stay at the facility. R1 stated could do these things on R1's own. Per R1's physician's report, R1 required some assistance with ADL's. During interviews conducted with S1-S4, (2) of (4) staff stated that R1 required minimal assistance with ADL's but was always assisted when it was needed or requested. During the interview conducted with R1-R10, (1) OF (10) residents stated they are unkempt. R5 stated that R5 did not receive a bath at all last week. R5 requires 3 baths per week, however admitted to refusing a bath on one day due to not feeling well. LPA observed all residents interviewed to have clean and full clothing, were well groomed, and had combed hair.

Regarding allegation: Resident is ridiculed by staff.
During the interview conducted with R1, it was stated that staff at the facility treated R1 well during R1's stay. R1 did not recall an incident where staff ridiculed R1 or any other resident at the facility. During interviews conducted with R1-R10, it was discovered that (10) of (10) residents did not have any knowledge of an incident where a staff ridiculed any resident, including themselves, at the facility. During interviews conducted S1-S4, it was discovered that (4) of (4) staff do not have any knowledge of any staff ridiculing any resident in care. S1-S4 stated that if they had knowledge of an incident of that nature, they would report it right away.

Regarding allegation: Resident was hit by unknown person.
During the interview conducted with R1, it was stated that R1 does not recall being hit by anybody at the facility, during R1's stay. (10) of (10) residents interviewed stated they have no knowledge of any incidents where residents or themselves were hit by other residents or staff at the facility. (4) of (4) Staff interviewed stated they have no knowledge of an incident where a resident was hit by another resident or staff. S1-S4 stated if they had knowledge of an incident of that nature, they would report it right away.

Based on LPA's interviews, observations, and record review, the investigation revealed: 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.

An exit interview was conducted with administrator Michele Goodney and a copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2