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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803745
Report Date: 02/08/2022
Date Signed: 02/08/2022 02:49:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:COUNTRY INN OF DOWNEYFACILITY NUMBER:
197803745
ADMINISTRATOR:ANA YESENIA GIRONFACILITY TYPE:
740
ADDRESS:11111 MYRTLE ST.TELEPHONE:
(562) 869-2401
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:150CENSUS: 72DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Ana Giron (Administrator)TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving at the facility LPA met with Ana Giron (Administrator) and explained the purpose of the visit. The Licensee prefers to serve 150 elderly residents. A maximum of 70 non-ambulatory residents may be in the facility.

A tour of the two story facility includes: Administrators office, living room, medication room, 1 elevator, kitchen, dining room, 2 public restrooms, 83 resident bedrooms each containing a bathroom, 1 staff bedroom, staff restroom, beauty shop, library, doctor's office and basement parking garage/storage/laundry.

During today's visit, LPA observed the following: Facility is not operating over capacity or beyond any conditions and limitation on the license. Pools is appropriately secured. No firearms on the premises. Facility maintain a comfortable temperature for residents. Bedrooms are equipped with furniture such as bed, chair, night stands, and overhead lighting. Licensee ensure grab bars for each toilet, bathtub and shower used by residents. Bathtub or shower have non-skid strips. The signal system is operational. Cleaning supplies are stored and locked in the basement. First aid kit has been inspected and has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, first aid manual are updated and it's available for staff use but inaccessible for residents. Smoke detectors and Carbon monoxide detectors are are operational. All fire extinguishers are fully charged. The total daily diet is of the quality and in the quantity necessary to meet the resident’s needs. A minimum of one week supply of nonperishable foods and 2 days of perishable foods were observed. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. Dishes, cups and flatware are stored in the kitchen cupboards are in good repair. Knives, cutlery and other sharp kitchen utensils are stored in the kitchen and only accessible to staff. Refrigerators, stove burners, oven, freezers, washer and dryers are operable. All outdoor and indoor passageways are kept free of obstruction. The facility has sufficient and competent staff to provide the services needed to meet resident needs. Staff assisting residents with ADLs has required training. Continue to LIC809C.....
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: COUNTRY INN OF DOWNEY
FACILITY NUMBER: 197803745
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2022
Section Cited

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87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a
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temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Hot water temperature measurements averaged 124 degrees F in various resident bathrooms.
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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: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: COUNTRY INN OF DOWNEY
FACILITY NUMBER: 197803745
VISIT DATE: 02/08/2022
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Criminal Record Clearance for all required persons is associated to the license. Staff responsible for direct care and supervision have current first aid training. Facility have a disaster and mass casualty plan. A certified Administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Medications are given per the physician’s directions. There is a signed and dated written order from a physician for every prescription and nonprescription PRN medication. Centrally stored medicines is kept in a safe and locked. Hot water temperature measurements averaged 124 degrees F in various resident bathrooms.

Per Title 22 Regulations, the deficiencies observed are documented on LIC809D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted and a copy of this report and appeal rights provided to Ana Giron.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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