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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 08/05/2021
Date Signed: 08/05/2021 05:36:53 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
08/03/2021 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20210803145611
FACILITY NAME:GARDENA RETIREMENT CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:AMY PRATTFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: DATE:
08/05/2021
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Susan Fuentes-AdminstratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident sustained multiple falls while in care
INVESTIGATION FINDINGS:
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On 08/5/21, Licensing Program Analyst (LPA) Stephanie CIfuentes conducted an unannounced complaint visit at this facility. LPA met with Susie Fuentes, Administrator, and explained the purpose of today's visit is to conduct interviews and to deliver findings.

The investigation consisted of the following: LPA interviewed Administrator Susie Fuentes. Interviews were conducted with seven (7) staff (S1-S7) and (7) residents (R1-R7). LPA inspected the facility. LPA reviewed records for residents 1-5 (R1-R5) along with the current staff/resident roster and other documents in association with the allegations.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
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 5
Control Number 11-AS-20210803145611
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: 08/05/2021
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:


Allegation: Resident sustained multiple falls while in care
The complainant reports (R1) fell several times in one day but the falls were unwitnessed. Staff #1 (S1) reports that she found R1 sitting on the floor in front of their wheelchair. S1 assessed R1’s range of motion and assisted them to their bed. At 9:30 PM S1 received a call from caregivers on shift and arrived at the room to find that R1 had fallen again and their wheelchair was on top of them. Another range of motion check was completed and R1 was checked for any bumps, bruises or bleeding, none were found and R1 stated they were in no pain. R1’s movement was a bit off, so the decision was made to call an ambulance to take R1 for evaluation to insure no unseen injuries. Interviews with (S1 to S7) show that 4 out of 7 staff state R1 has a history of falling. Per R1’s records, resident is unable to transfer without aid, but there is no fall care plan in place.

Based on LPA’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of "Resident sustained multiple falls while in care" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview was conducted with Susie Fuentes. The Rights were discussed and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report to the Administrator.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/03/2021 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20210803145611

FACILITY NAME:GARDENA RETIREMENT CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:AMY PRATTFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: DATE:
08/05/2021
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Susan Fuentes-AdminstratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff did not seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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On 08/5/21, Licensing Program Analyst (LPA) Stephanie CIfuentes conducted an unannounced initial complaint visit at this facility. LPA met with Susie Fuentes, Administrator, and explained the purpose of today's visit is to tour facility ground, inspect records, conduct interviews and to deliver findings.

The investigation consisted of the following: LPA interviewed Administrator Susie Fuentes. Interviews were conducted with seven (7) staff (S1-S7) and (7) residents (R1-R7). LPA inspected the facility. LPA reviewed records for residents 1-5 (R1-R5) along with the current staff/resident roster and other documents in association with the allegations.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210803145611
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: 08/05/2021
NARRATIVE
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Allegation: Facility staff did not seek medical attention in a timely manner
The complainant reported (R1) did not arrive to the hospital in a timely manner after multiple falls. Interview with (S1) disputes this allegation and states that a non-emergency ambulance was called immediately as (R1) stated they were in no pain and no blood or bruises were found, however there was a several hour wait for pick-up. Administrator states she was informed by (S1) that several ambulance services were called, all stated that there were long waits that evening and it would be several hours before a pick-up could happen. In addition, the transport was delayed and the facility had no other method of transporting the resident.
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 records, incident report, and interviews conducted and found no evidence to support the allegation:"Facility staff did not seek medical attention in a timely manner".

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 allegation is Unsubstantiated.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210803145611
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Administrator will provide CCL with fall risk plan by POC due date.
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Based on interviews, observation, and record review, on 8/5/2021, LPA observed that R1, a fall risk, did not have a fall prevention plan which poses a potential health risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5