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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 12/03/2021
Date Signed: 12/04/2021 12:51:50 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
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/29/2021 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211129153350
FACILITY NAME:GARDENA RETIREMENT CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:SUSANA FUENTESFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: 67DATE:
12/03/2021
UNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Susana FuentesTIME COMPLETED:
02:04 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/3/2021 at 12:03 p.m., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by Administrator Susana Fuentes. LPA explained to Ms. Fuentes the purpose of the visit. The investigation consisted of the following: LPA and Ms. Fuentes conducted an inspection, for health and safety of the facilities’ physical plant, R1's resident room, and food supply, LPA conducted an interview with Administrator Susana Fuentes, and LPA was provided the following documents from Administrator Susana Fuentes: LIC 500-staff roster; Client roster; Incident Reports from November 2021 to present; R1 case notes; R1 physician report; and R1 service care plan. LPA was informed by Administrator Susana Fuentes that R1 was not evicted, from the facility, and that R1 can return to the Gardena Retirement Center upon discharge from medical facility. Based on information gathered, LPA did not find sufficient evidence to support allegation " Illegal Eviction”. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Susana Fuentes, Administrator, and a hard copy of a LIC 9099 was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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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