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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803745
Report Date: 01/31/2025
Date Signed: 01/31/2025 01:26:53 PM

Document Has Been Signed on 01/31/2025 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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:COUNTRY INN OF DOWNEYFACILITY NUMBER:
197803745
ADMINISTRATOR/
DIRECTOR:		ANA YESENIA GIRONFACILITY TYPE:
740
ADDRESS:11111 MYRTLE ST.TELEPHONE:
(562) 869-2401
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 150CENSUS: 72DATE:
01/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Patricia Hernandez - Front OfficeTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Patricia Hernandez (Receptionist) and explained the purpose for today’s visit, shortly after Administrator Ana Giron arrived to assist with the visit. The facility is licensed to serve 150 Ambulatory Elderly Residents ages 60 and above, of which 70 may be Non-Ambulatory. Facility holds a hospice waiver for up to 5 Residents. (there are currently 0 residents utilizing hospice services)

The Facility is a 2 story building located in Downey, CA. A tour of the facility included: 1st floor: Multiple resident rooms with private full bath, Kitchen, Dining Area, Laundry Room, Storage Closets (for cleaning/janitorial supplies), TV Room, Medication Room, Staff Restroom, Staff Office, Lobby, Reception Area, Staff Break Room, and Outdoor Patio. 2nd floor: Multiple resident rooms with private full bath, Doctor Room, Staff Restroom, and Library. There is one elevator that LPA observed to be in working condition.



LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today:
Infection Control: Facility has sufficient PPE supplies and the required Infection Control Plan.
Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Hospice Plan and training. Facility maintains the required liability insurance.
Physical Plant & Environment Safety: LPA toured facility, a total of 6 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom and in bedroom that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There is a large shaded patio area on the first floor for residents. (Continued on LIC809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: COUNTRY INN OF DOWNEY
FACILITY NUMBER: 197803745
VISIT DATE: 01/31/2025
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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.
Personnel Records-Training: Staff have criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, Hospice Services and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator Ana Giron Administrator Certificate expired on 10/20/24 LPA was able to verify renewal in CCL website and Administrator is in the pending list with receipt date of 9/26/24.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 7 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone at the facility. LPA observed the following posters posted on the first floor: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled, centrally stored and are in their original containers. Staff that assist with medication administration have the needed training in their files. LPA reviewed 7 Residents medications during visit with no issues.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 12/19/24.
Residents with Special Health Needs: Facility accepts residents on Hospice Care and staff files reviewed today all have required training documented. (there are currently no residents using hospice services)

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held, a copy of this report will be emailed to Ana Giron at giron_counrtyinnofdowney@yahoo.com.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC809 (FAS) - (06/04)
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