198601838-8-31-2022-28-AS-FFIS-CJC2V3-20220916174313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601838
Report Date: 08/31/2022
Date Signed: 08/31/2022 10:25:38 AM

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 CENTER		FACILITY NUMBER:	198601838
ADMINISTRATOR:	MICHELE R GOODNEY		FACILITY TYPE:	740
ADDRESS:	11500 DOLAN AVENUE		TELEPHONE:	(562) 869-2416
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	252	CENSUS: 105	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Michele Goodney (Administrator)		TIME COMPLETED:	10:30 AM

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.
Facility did not notify conservator regarding the facility not being able to refill resident's medication.

INVESTIGATION FINDINGS:

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***This LIC9099 report supersedes LIC9099A report dated 12/13/21.***

Licensing Program Analyst (LPA) Kruz Long re-delivered complaint findings for the above allegations. LPA met with Michele Goodney (Administrator) and explained the purpose of the visit.

During a site visit conducted on 12/13/21, 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..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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-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: 08/31/2022

NARRATIVE

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***This LIC9099C report supersedes LIC9099C report dated 12/13/21.***

Records indicate the facility made attempts on 11/03/21 and 11/25/21 to contact the primary care physician and the conservator to obtain medication refill but did not receive a response.

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. Records indicate the facility made attempts on 11/03/21 and 11/25/21 to contact the primary care physician and the conservator to obtain medication refill but did not receive a response.

In regards to the allegation: Facility did not notify conservator regarding the facility not being able to refill resident's medication. Records indicate the facility made attempts on 11/03/21 and 11/25/21 to contact the primary care physician and the conservator to obtain medication refill but did not receive a response.

Based on LPA's interviews and record review, the 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 Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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