197803745-10-9-2025-28-AS-WSHO-DMQMLU-20251023094252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 10/09/2025
Date Signed: 10/09/2025 03:12:49 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
10/01/2025 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20251001124708

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: 84	DATE:	10/09/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Erika Becerra - Assistant Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not provide medication assistance to resident in care.

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 2 ( S1 - S2), interviews with Resident 1- Rsident 8 (R1 - R8). LPA obtained a copy of the Staff and Resident Roster, R1'Medication Administration Record (September / October 2025), Admission Agreement, Face Sheet, Physitian's Report, Resident Appraisal, Appreaisal/ Needs and Services, Transfer/ Discharged Report, SIR dated on 10/01/25.

Continue 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

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-20251001124708

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: 10/09/2025

NARRATIVE

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Allegation: Staff did not provide medication assistance to resident in care. It was alleged that R1 asked staff for their prescribed medications, but staff refused to provide them to resident.

Interviews conducted with Administrator and staff revealed that facility residents receive their medications on a daily basis as prescribed by their doctor. Facility staff stated that they didn't refuse to assist residents with any medical needs. They always assist residents with their medications, and the medications are given to residents as prescribed by the doctor. interviews revealed that some residents are independent and prefer to handle their own medical needs, R1 is one of them. However, there is an in-house primary physician who visit residents on a monthly basis and this option is offered upon admission. R1 was moved to the facility on 09/15/25 and expressed to staff that they have their own primary doctor and will continue to see them (R1 responsible for own self). Staff obtained the provider information and called the clinic to get updated information and medication orders for R1. After several unsuccessful attempts to get hold of someone from the clinic, staff spoke with R1 and recommended to see one of facility providers and explained that R1 need to be seen by doctors to get their medications. R1 agreed to see an in-house doctor, but when R1 was seen on 10/01/25, R1 mentioned that they have an appointment to see their own doctor on 10/03/25. In house doctor told R1 that it is fine but meanwhile he will prescribe medications so R1 won't be without medication. Interviewed R1 stated that they was not able to contact their own primary doctor since 10/03/25. R1 stated that he/she is getting their medications and facility staff help with medical needs. Interviewed residents stated that facility staff assisted them with medications and didn't refuse to provide medications. They stated they don't have any concerns about this matter.

Based on statements and interviews conducted with staff and clients, review of records, 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 was held, and a copy of this report was provided to Administrator Ana Giron.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025

LIC9099 (FAS) - (06/04)

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