197607366-1-26-2022-11-AS-MCAA-CB9VCR-20220202151935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 01/21/2022
Date Signed: 01/26/2022 08:03:43 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
01/18/2022 and conducted by Evaluator Susan Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220118134839

FACILITY NAME:	GARDENA RETIREMENT CENTER		FACILITY NUMBER:	197607366
ADMINISTRATOR:	SUSANA FUENTES		FACILITY TYPE:	740
ADDRESS:	14741 S. VERMONT AVE.		TELEPHONE:	(310) 327-4091
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	108	CENSUS: 64	DATE:	01/21/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Susana Fuentes		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not respond to resident's call button in a timely manner.

INVESTIGATION FINDINGS:

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

On 1/21/2022 at 2:40pm, Licensing Program Analyst (LPA)/ Susan Campos, initiated a subsequent 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 conducted interviews with (6) staff members, and (6) residents on 1/20/22, and (2) staff members on 1/21/22. 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 Staff Call Button Response Procedures.

Report continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (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 2

Control Number 11-AS-20220118134839

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

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

Allegation: Staff do not respond to resident's call button in a timely manner

The investigation revealed, per LPA interviews, with (8) staff members, and (6) residents from the Gardena Residential Center, and also review of facility documents, that staff respond to resident’s call button. S1 informed the LPA, that is not aware of a resident’s room call button not responded to by a staff person. In addition, S1 informed LPA that all call bottom signal requests, go to the facility main office, and the office manager or med techs, responds first by intercom, to the resident’s call box, and then asks the resident what assistance do they need, and also lets the resident know that a staff person will go to their room to assist. Additionally, the LPA interviewed (8) Gardena Retirement Center staff persons, and 8 of 8 staff members interviewed, informed the LPA, that the facility staff personnel, responds to the resident room call button signals. Also, 8 of 8 staff members, informed the LPA, that the staff, at the main office, once they receive a call button request, respond to the resident’s call button, first by intercom, asking the resident what assistance do they need, and also informing the resident, that a staff person is on their way to the resident’s room. Furthermore, 8 of 8 staff members, informed the LPA, that they are not aware of a resident call button request that was not answered by a staff person. In addition, the LPA interviewed S7 and S8, scheduled at the main desk on 1/15/22 during morning hours, and was informed that while stationed at the main office desk on 1/15/22, they did not receive a call button request from R1. Additionally, the LPA interviewed (6) residents, and 5 of 6 residents interviewed, informed the LPA, that they do not use the call button. On 1/21/22, at 1:40 pm, the LPA observed the facility front office video camera, for 1/15/22 from 10:45 am to 11:05am, and observed per video footage, two staff persons at the front desk area, and also other staff persons walking past the front desk area. In addition, on 1/20/22, the LPA also observed 6 facility resident room call button stations, and observed that all 6 resident room call button stations are operable.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff do not respond to resident's call button in a timely manner”

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Administrator Susana Fuentes.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (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 2