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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 01/21/2022
Date Signed: 01/26/2022 07:52:54 AM



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
01/14/2022 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220114104631
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: 64DATE:
01/21/2022
UNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Susana FuentesTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility is not assisting resident with transportation needs.
Facility does not have required postings in public view.
INVESTIGATION FINDINGS:
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On 1/21/2022 at 1:03 pm, Licensing Program Analyst (LPA)/ Susan Campos, initiated a subsequent complaint investigation visit for the allegations 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 conducted interviews with (6) staff members, and (6) residents on 1/20/22. In addition, on 1/20/22, LPA and Ms. Fuentes conducted an inspection, for health and safety of the facilities’ physical plant, and food supply, and also inspected (6) facility resident room call button box stations. LPA also reviewed the following documents provided by Gardena Retirement Center Administrator Susana Fuentes: LIC 500-staff roster, client roster, staff schedule, Incident Reports from December 2021 to present, and Facility Resident Transportation Services Plan .

Report continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
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 4
Control Number 11-AS-20220114104631
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
MONTEREY PARK, CA 91754
FACILITY NAME: GARDENA RETIREMENT CENTER
FACILITY NUMBER: 197607366
VISIT DATE: 01/21/2022
NARRATIVE
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Allegation: Facility is not assisting resident with transportation needs

The investigation revealed, per LPA interviews, with (6) staff members, and (6) residents from the Gardena Residential Center, and also review of facility documents, that the facility, does not assist residents with transportation to medical appointments per admission agreement policy. S1 informed the LPA that the facility assists residents with transportation to their medical appointments. S1 also stated that the facility does not have a transportation van, but will assist residents with their medical transportation appointments, if requested, by using Lyft transportation services. S1 informed LPA, that most residents in the facility, handle their own transportation to their medical appointments, and do not ask S1 for assistance; however, if medical transportation is needed, then S1 states that will assist the resident with transportation, to their medical appointment. S1 informed, the LPA that the facility has a company Lyft account, that is used for resident medical appointment transportation trips. The facility will pay for resident transportation medical appointments, up to 5 miles distance from the facility. Also, S1 informed the LPA, that currently, there are only a few residents, that ask for medical transportation assistance, because resident family members, assist residents with transportation to their medical appointments or residents will call Access paratransit services to obtain transportation assistance to their medical appointments. In addition, the LPA interviewed (6) Gardena Retirement Center staff persons and 6 of 6 staff members interviewed, informed the LPA, that most facility residents make their own transportation arrangements, to their medical appointments using Access paratransit services or with family assistance. And also, 3 of 6 staff members, informed the LPA, that the residents pay for their transportation to their medical appointment when they use Access paratransit services or if the facility arranges for Lyft services. Furthermore, the LPA interviewed (6) residents, and 3 of 6 residents interviewed, informed the LPA, that they arrange their own transportation to their Medical appointments, and the other 3 of 6 residents interviewed informed the LPA that they do not have doctor appointments. Also 4 of 6 residents interviewed informed the LPA, that if S1 arranges Lyft services, for transportation to medical appointments, the resident is responsible for paying for the Lyft trip. The other 2 of 6 residents interviewed informed the LPA that they do not know, if the facility, provides transportation assistance for resident medical appointments.



On 1/20/22, at 3pm, LPA reviewed the facility Resident Admission Agreement, and the agreement states on page 3, “In the event that Your family and/or Responsible Party are not able to, the community will make

Report continued on LIC 9099C
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 11-AS-20220114104631
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
MONTEREY PARK, CA 91754
FACILITY NAME: GARDENA RETIREMENT CENTER
FACILITY NUMBER: 197607366
VISIT DATE: 01/21/2022
NARRATIVE
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arrangements for transportation (within a 5 mile radius) for you in order to meet your necessary medical and/ or dental needs.” Per LPA interviews with facility staff and residents, the facility policy is not being implemented.

Based on information gathered, the LPA did find sufficient evidence to support allegation " Facility is not assisting resident with transportation needs per admission agreement policy”.



Allegation: Facility does not have required postings in public view

The investigation revealed, per LPA observation, that the LPA did not observe, posting of required documents in the facility entry or lobby area. S1 informed the LPA, that S1 had taken down, the facility license, from the lobby hall wall, because the wall was being painted, and that the facility license would be placed, back on the wall, once the wall paint dried. The LPA informed S1, that when there are facility repairs, in the location, of the facility posted license, S1 will need to relocate the documents to another public view location, while the facility repair is taking place. S1 also informed the LPA, that in the past, there have been instances, of the removal of documents, placed on the lobby hall wall, and that, in the future, the facility will be using a glass case, in the lobby hallway, for required posted documents, in order to prevent these incidences from reoccurring. S1 informed the LPA, that video cameras have been re-positioned in the facility lobby hallway, in order to observe, the safety of all required posted documents. LPA informed S1, to please submit incident reports, to the Department of Social Service Community Care Licensing, for all cases of document tampering, and theft, and to immediately replace missing posted documents.

On 1/20/22, at 1:10pm, LPA observed that the facility, did not have facility license, posted in public area. And on 1/20/22, at 1:20pm, S1 placed the license on the facility lobby hallway.

Based on information gathered, LPA did find sufficient evidence to support allegation " Facility does not have required postings in public view ”

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Susana Fuentes, Administrator and a hard copy of a LIC 9099 and LIC 9099D was provided.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20220114104631
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
MONTEREY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER
FACILITY NUMBER: 197607366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2022
Section Cited
HSC
87465(a)(2)
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87465Incidental Medical and Dental Care(a)(2)(a)...(2)The licensee shall provide assistance in meeting necessary medical and dental needs...y which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.
This requirement is not met as evidenced by:
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Administrator will fax to LPA a copy of the Gardena Residential Center - Resident Medical Transportation Plan, and also its notification plan to Resident and Staff.

POC Due Date is 2/7/22
LPA Fax Number (323)981-1781
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Based on interviews, and record review, on 1/20/22, LPA was informed, per interviews, by 4 of 6 residents and 3 of 6 staff persons, that the facility does not pay for resident medical transportation trips as stated in admission agreement, which posed a potential health risk to residents in care.
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Type B
01/20/2022
Section Cited
HSC
87113
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87113 Posting of License.
The license shall be posted in a prominent location in the licensed facility accessible to public view.
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On 1/20/21, Administrator posted Gardena Retirement Center license on facility lobby wall.



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On 1/20/22 at 1:10pm, LPA observed that the Gardena Residential Center license was not posted in the lobby for public view.
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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: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4