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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197803745
Report Date: 11/04/2025
Date Signed: 11/06/2025 08:01:28 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/29/2025 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251029103225
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: 86DATE:
11/04/2025
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Administrator- Ana GironTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not ensure resident's room was not in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vaid conducted an unannounced 10-day initial visit to the facility and was met by Assistant Administrator /Med-tech Erika Becerra and the reason of the visit was discussed.

LPA Vaid requested and obtained the resident roster, staff roster. Residents #1-#3 (R1-R3)- face sheet, physicians report, preplacement report. Administrator Ana Giron arrived shortly after to assist with the visit. LPA Vaid and Administrator Giron toured the facility and did not observe any health and safety concerns.

Regarding the allegation: Staff did not ensure resident's room was not in disrepair. It is alleged that the staff are not ensuring residents’ room was not in disrepair, a broken window and floor tile have not been fixed for over one and half years months (18 months) and staff are not repairing the broken items.

Continued on 9099C................................
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20251029103225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COUNTRY INN OF DOWNEY
FACILITY NUMBER: 197803745
VISIT DATE: 11/04/2025
NARRATIVE
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Five (5) of five (5) staff interviewed stated repairs are reported by the staff during their rounds and reported to the administrator (S1), S1 notifies the corporate office to authorize vendor repairs to the facility. According to S1 all large repairs are done through hired vendors, small repairs are handled by the janitorial/maintenance staff. Residents are encouraged to report all repairs to the front office. Small repairs are made immediately by the janitorial/maintenance staff and large repairs are done by authorized vendors within 24 hours depending upon the issue. Seven (7) out of eight (8) residents interviewed stated they report broken items to the staff and repairs are made. Five (5) of eight (8) residents stated they report necessary repairs to the front office and repairs are made within 24 hours for minor repairs. Observations made by LPA to rooms during tour with S1 and did not observe broken window nor missing floor tiles in rooms #6- #10. LPA Vaid did not observe missing tiles, only mismatching repaired floor tiles. LPA Vaid toured R1’s room, bathroom does not have a window, there is only one window in the room and the window is not in disrepair. Observation of floor tiles are not in disrepair. Based on interviews conducted and observations made. 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 conducted and report was provided to Administrator- Ana Giron.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2