197607366-10-19-2021-11-AS-MVAO-C9JQZ3-20211209113604

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 10/19/2021
Date Signed: 10/19/2021 04:33:32 PM

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 DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20211004141720

FACILITY NAME:	GARDENA RETIREMENT CENTER		FACILITY NUMBER:	197607366
ADMINISTRATOR:	AMY PRATT		FACILITY TYPE:	740
ADDRESS:	14741 S. VERMONT AVE.		TELEPHONE:	(310) 327-4091
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	108	CENSUS: 71	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Susana Fuentes		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents meals are late
Residents bed is in disrepair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent investigation at the facility listed above. LPA spoke with staff Elizabeth via telephone call prior to entering the facility to conduct risk assessment questionnaire and was informed that facility had no COVID cases nor do any of the clients have symptoms. LPA arrived at facility and was greeted by staff. LPA explained the purposed of the visit was to investigate the allegations listed above and was granted access to the facility.

The investigation consisted of the following: LPA interviewed Administrator Susie Fuentes. Interviews were conducted with six (6) staff (S1-S6) and six (6) residents (R1-R6). LPA inspected the facility. LPA reviewed records for residents 1-6 (R1-R6) along with the current staff/resident roster and other documents in association with the allegations.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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 11-AS-20211004141720

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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 10/19/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Residents meals are late
The complainant alleges that resident 1’s (R1’s) lunch has been late twice. LPA spoke with administrator Susie Fuentes, who stated that residents’ meals served in the dining room are not late. They might receive an item like water a little later, but they are served on time Per staff each meal has two seatings, one for those who need assistance with dinning and the second for those that are independent. Staff also agreed that food was not served late, but another item accompanying the meal could be served a little later, depending LPA interviewed residents (R1-R6) and of those interviewed, one stated they did not eat the food while 4 out of the 6 stated the meals at the facility are not late. LPA spoke to staff regarding resident meals and 5 out of 6 stated residents meals are not late.

Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

Allegation: Residents bed is in disrepair

The complainant alleges R1’s bed is in disrepair and they can feel the springs. LPA spoke with Administrator, who stated she was not aware of any beds in disrepair. LPA toured facility grounds and checked the beds in several rooms. LPA Cifuentes did not feel any springs poking out of any of the beds. LPA spoke with residents (R1-R6) regarding their beds and 6 out of 6 residents stated their bed is not in disrepair. LPA spoke with staff (S1-S6) regarding residents’ beds and 5 out of 6 staff staff stated residents beds are not in disrepair

Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R-1)'s service records, incident report, and interviews conducted and found no evidence to support the allegations: “Residents meals are late”, “Residents bed is in disrepair”.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Susie Fuentes and a copy of the report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2