197803745-9-16-2025-28-AS-WSHO-DLYVBQ-20250929161756

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 09/16/2025
Date Signed: 09/16/2025 03:23:50 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
09/11/2025 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20250911143350

FACILITY NAME:	COUNTRY INN OF DOWNEY		FACILITY NUMBER:	197803745
ADMINISTRATOR:	ANA YESENIA GIRON		FACILITY TYPE:	740
ADDRESS:	11111 MYRTLE ST.		TELEPHONE:	(562) 869-2401
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	150	CENSUS: 86	DATE:	09/16/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Erika Becerra - assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Due to lack of supervision, resident physically assaulted another resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator. Administrator Ana Giron arrived shortly after and assisted with the visit. Purpose of the visit was explained.

The investigation consisted of the following: Interviews with Administrator, Staff 1 - Staff 4 ( S1 - S4), interviews with Resident 1- Rsident 9 (R1 - R9), Family Member 1( FM1) and Family Member 2 (FM2), tour the facility. LPA observed residents in the common area watching television and also sitting outside in the patio area. Review of R1's file and facility staff schedule. Facility Staff and Residents roster were obtained.

Continue 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

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-20250911143350

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: COUNTRY INN OF DOWNEY	FACILITY NUMBER: 197803745
	VISIT DATE: 09/16/2025

NARRATIVE

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Allegation: Due to lack of supervision, resident physically assaulted another resident. It was alleged that R1 had a bruise near their eye and R1 did not remember how they got the bruise (it was from falling or R2 hit R1).

Interviewed Administrator and staff denied the allegation and stated that there are enough staff on schedule throughout the day and during the night to properly supervise all residents in care as well as to ensure that all residents are safe at all times. Interviewed Administrator stated that R1 has the tendency of making up stories so they can have their way. Interviewed Administrator and staff stated that they were not witnessed that R2 or another resident hit R1. Administrator stated that on Sunday R1's FMs came to visit them and R1 told FMs that R2 just hit them. R2 was in the patio with R1 and R1's FMs at the time of R1's FM visitation. FMs apologize to R2 and told R2 they saw that R2 not gotten close to R1 at all (Copy of SIR dated 9/14/25 was provided to LPA). Interviewed FM1 and FM2 confirmed that R2 did not hit R1. FMs stated that they didn't notice any bruises on R1, but there was a red mark on R1's face close their right eye and could be because of R1's dry skin. Interviewed staff stated that they noticed dry skin by R1 right eye and applied lotion. They remind R1 to always apply lotion and not scratch their face. Interviewed S3 and S4 stated that R1 sleep on their right side and put hands under the face (sometimes R1 put their purse under the face). They stated that R1 has 2-3 big rings on both their hands, and it could be the reason for redness of skin and possibly bruises. Interviewed R1 said that R2 hit them but could not provide any details regarding the incident. Interviewed R2 stated they didn't hit R1. Additional residents interviewed have not observed R2 or any other resident hitting R1 or another resident. LPA did not observe any bruises on R1 but noticed very faint redness on R1's face near right eye. LPA review of staff roster revealed that the facility has adequate staff on schedule.

Based on statements gathered from interviews conducted with staff, residents and observations, there was not enough supportive evidence to concur with the reported allegation. 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.

Exit interview conducted with Administrator and the copy of this report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025

LIC9099 (FAS) - (06/04)

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