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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 08/05/2021
Date Signed: 12/08/2021 03:16:03 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
07/06/2021 and conducted by Evaluator Stephanie Cifuentes
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210706130137
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:
03:16 PM
MET WITH:Susie FuentesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident missed her medical appointment
Staff refused to provide transportation for resident's medical appointments
Staff failed to meet residents' hygiene needs


INVESTIGATION FINDINGS:
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This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created 8/5/2021.

On 08/5/21, Licensing Program Analyst (LPA) Stephanie CIfuentes conducted an unannounced subsequent complaint visit at this facility. LPA met with Administrator Susie Fuentes and explained the purpose of today's visit is to deliver findings.

The investigation consisted of the following: On 7/8/2021 LPA Cifuentes spoke with administrator, reviewed facility records, was given a tour of facility grounds and interviewed residents 1-resident 5 (R1-R5) as well as staff 1-staff 4 (S1-S4). On 7/20/2021 LPA interviewed residents 6-resident 7 (R6-R7) as well as staff 5-staff 6 (S5-S6). LPA also requested and received the following: staff roster, resident roster and other documents relevant to the allegations.

Continued on 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: 1 of 6
Control Number 11-AS-20210706130137
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 missed her medical appointment

The complainant alleges resident was notified two days before a medical appointment that facility would no longer be providing transportation to and from their medical appointments, causing resident to miss their appointment. LPA reviewed facility admissions agreement page 3, which states facility will assist with necessary medical or dental transportation at cost listed, which depends on the amount of time needed for the trip. LPA spoke with administrator Susie Fuentes regarding missed medical appointments for residents. Per Administrator Fuentes the facility does not have its own vehicle to use for resident transportation. The facility was using Uber to get residents to their appointments and had not been charging them. Ms. Fuentes stated she informed residents that Uber was still available, but facility would be charging for its use. As a result, some residents used Uber to get to their medical appointments while others used a transportation service like Access or contacted their families for transport. Per Ms. Fuentes, no residents missed their medical appointments, nor did they need to reschedule. LPA spoke to residents (R1-R7) regarding missed medical appointments. Resident mentioned in allegation was not available for interview. Out of those interviewed, 5 out of the 7 stated they have not missed medical appointments. LPA also interviewed staff (S1-S6) and 4 out of the 6 stated residents had not missed medical appointments.

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


Allegation: Staff refused to provide transportation for resident's medical appointments

The complainant reported staff have refused to provide transportation for resident’s medical appointments. LPA spoke to administrator who stated facility has Lyft account, she has used uber for one residents appointments and other residents have set-up Access services, use medical transportation or Gardena transit. LPA was given copies of Uber receipts. LPA interviewed residents (R1-R7) about transportation and was told they use a variety of the following: the facility helps set it up, they use Access, drive, public transport or medical transport. When asked if the facility assisted with transportation 5 out of 7 state the facility helps. LPA also asked if facility had ever refused to assist them with transportation, and 4 of the 7 said no. LPA interviewed staff (S1-S6) about transportation, and was told by 5 out of 6 that facility assists with transportation.



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

Continued on 9099-C
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 6
Control Number 11-AS-20210706130137
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: Staff failed to meet residents' hygiene needs

The complainant reports resident’s family buys hygiene products for the resident because facility does not provide them. LPA reviewed admissions agreement page 4, which states the facility will assist with the ordering of supplies and assist with personal hygiene. Administrator stated that facility provides supplies for those on the Healthy Families program but for everyone else the resident or the family is responsible to provide hygiene supplies. The facility does have a stock of donated care packages which are given to those who don’t have supplies. LPA interviewed residents (R1-R7) and of those interviewed, 7 out of 7 stated the facility did not provide hygiene supplies and 5 of those 7 indicated they could purchase it on their own. LPA spoke to staff regarding hygiene supplies and 5 out of 7 stated facility does not provide hygiene supplies.


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 (R1)'s service records, incident report, and interviews conducted and found no evidence to support the allegations: "Resident missed her medical appointment, Staff refused to provide transportation for resident's medical appointments, Staff failed to meet residents' hygiene needs

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 by email.
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: 3 of 6
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
07/06/2021 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20210706130137

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:
03:16 PM
MET WITH:Susie FuentesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Insufficient staffing to meet the residents' needs
INVESTIGATION FINDINGS:
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On 08/5/21, Licensing Program Analyst (LPA) Stephanie CIfuentes conducted an unannounced subsequent complaint visit at this facility. LPA met with Susie Fuentes, Administrator and explained the purpose of today's visit is to deliver findings.

The investigation consisted of the following: On 7/8/2021 LPA Cifuentes spoke with administrator, reviewed facility records, was given a tour of facility grounds and interviewed residents 1-resident 5 (R1-R5) as well as staff 1-staff 4 (S1-S4). On 7/20/2021 LPA interviewed residents 6-resident 7 (R6-R7) as well as staff 5-staff 6 (S5-S6). LPA also requested and received the following: admissions agreement for R1 , staff roster and resident roster.

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: 4 of 6
Control Number 11-AS-20210706130137
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: Insufficient staffing to meet the residents' needs

The complainant reported that whenever residents need help the staff does not assist them in a timely manner due to lack of staffing. LPA spoke to administrator who stated that she believed the facility could use a few more staff and that she was in the process of hiring more. LPA interviewed residents regarding the lack of staffing and of the 7 interviewed, 6 stated that there was not enough staff. Interviews with staff showed that 2 out of 6 staff believe there is not enough staff.



Based on LPA’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of "Insufficient staffing to meet the residents' needs" 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: 5 of 6
Control Number 11-AS-20210706130137
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
87411(a)
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Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
This requirement was not met as evidenced by:
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Administrator will provide plan to LPA to insure sufficient staff are available for each shift to cover residents needs. Will submit to CCL by POC due date.
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Based on interviews, observation, and record review, on 8/5/2021, LPA that facility does not have sufficient staff 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: 6 of 6