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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 12/13/2021
Date Signed: 12/13/2021 01:46:47 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
12/07/2021 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211207131830
FACILITY NAME:DOWNEY RETIREMENT CENTERFACILITY NUMBER:
198601838
ADMINISTRATOR:MICHELE R GOODNEYFACILITY TYPE:
740
ADDRESS:11500 DOLAN AVENUETELEPHONE:
(562) 869-2416
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:252CENSUS: 103DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Michele Goodney (Administrator)TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff refused to give resident their prescribed medications.
Facility staff did not notify resident's responsible party of change in resident's condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Michele Goodney (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff Schedule/Resident Roster, Medication Plan of Operation, Resident #1's medication administration record (Nov/Dec 2021), Face sheet and Charting notes. LPA also interviewed Staff #1 in the office at 10:44 am and Resident #1 in the office at 11:19 am.

In regards to the allegation: Facility staff refused to give resident their prescribed medications. Based on record review, assistance with prescribed medication administration was not completed from December 1, 2021 to December 6, 2021 for Resident #1 was due to the fact that facility was not able to obtain authorization to refill prescription medications and not a refusal to assist Resident with medications. Interviews with Staff and Resident indicate that Staff did not refuse to give Resident their prescribed medication. Continue to LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 5
Control Number 28-AS-20211207131830
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: 12/13/2021
NARRATIVE
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In regards to the allegation: Facility staff did not notify resident's responsible party of change in resident's condition. Based on interviews with Witness, Staff and Resident, there were no apparent change in Resident's condition during the time prescribed medications were not administered. There are no medical records revealing Resident had a change of condition due to not receiving prescribed medications.

Based on LPA's record review and interviews, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Michele Goodney and a copy of this report provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/07/2021 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211207131830

FACILITY NAME:DOWNEY RETIREMENT CENTERFACILITY NUMBER:
198601838
ADMINISTRATOR:MICHELE R GOODNEYFACILITY TYPE:
740
ADDRESS:11500 DOLAN AVENUETELEPHONE:
(562) 869-2416
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:252CENSUS: 103DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Michele Goodney (Administrator)TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident did not receive their prescribed medications for an extended period of time.
Facility staff did not ensure that resident received medication refills.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Michele Goodney (Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff Schedule/Resident Roster, Medication Plan of Operation, Resident #1's medication administration record (Nov/Dec 2021), Face sheet and Charting notes. LPA also interviewed Staff #1 in the office at 10:44 am and Resident #1 in the office at 11:19 am.

In regards to the allegation: Resident did not receive their prescribed medications for an extended period of time. Based on record review and interviews, Resident #1 did not receive their medication from Dec. 01, 2021 to Dec. 06, 2021 because facility was not able to obtain refill authorization from doctor.

Continue to LIC9099C.....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 5
Control Number 28-AS-20211207131830
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: 12/13/2021
NARRATIVE
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In regards to the allegation: Facility staff did not ensure that resident received medication refills. Based on record review and interviews, Resident #1's prescription medications were not refilled in a timely manner causing Resident #1's prescription medications not being administered from Dec. 01, 2021 to Dec. 06, 2021.

Based on LPA's record review and interviews, investigation revealed that the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Failure to provide proof of corrections may result in civil penalties.

Exit interview conducted with Michele Goodney and a copy of this record and appeal rights provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20211207131830
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2021
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(5) The licensee shall assist residents with self-administered
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Licensee shall provide additional training to all Staff responsible for medication assistance and provide proof to the department by the POC date.
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medications as needed. This requirement is not met as evidenced by: Resident #1 did not receive their medication from Dec. 01, 2021 to Dec. 06, 2021 because facility was not able to obtain refill authorization from doctor.
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Type A
12/14/2021
Section Cited
CCR
87465(e)
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 Incidental Medical and Dental Care
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain
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Licensee shall revise Medication Plan of Operation to ensure that future medication refills are requested and obtained in a timely manner.
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at least all of the following information. This requirement is not met as evidenced by: Resident #1's prescription medications were not refilled in a timely manner causing Resident #1's prescription medications not being administered from Dec. 01, 2021 to Dec. 06, 2021.
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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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5