197607366-3-10-2022-11-AS-EMAZ-CCZQ42-20220330114936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:16:30 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
12/16/2021 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211216155411

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:	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Administrator, Susana Fuentes		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility is not following COVID-19 guidelines.
Resident is being illegally evicted.
Facility is retaliating against resident for making complaints.

INVESTIGATION FINDINGS:

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On 03/10/22 at 8:00 a.m. Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros, conducted an unannounced subsequent complaint investigation visit regarding the above-mentioned allegations. LPA Stephanie Cifuentes conducted the initial 10-Day visit on 12/21/21. Staff #1 (Mari Banuelos, Med Tech) confirmed that the facility had no new COVID cases nor do any of the residents have symptoms and LPA/RA was allowed entry into the facility. LPA/RA Ceniceros spoke with Administrator Susana Fuentes (via telephone) approx. 8:15 a.m. and was later met by Administrator (Suzanna Fuentes) approx. 9:00 a.m. LPA/RA at that time explained the purpose of today's visit.

The investigation consisted of the following: LPA/RA conducted interviews with (9) facility staff and (7) residents. LPA/RA Ceniceros and Administrator Fuentes conducted an inspection of the facility’s physical plant for health and safety measures; observation of state-issued License and Administrator Certificate are

(Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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 3

Control Number 11-AS-20211216155411

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: 03/10/2022

NARRATIVE

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posted in a prominent place, sufficient 60-day supply of required personal protective equipment; reviewed R1's physician's report, medication administration record, cash resources (from 01/01/20 - 01/21/22), trust transaction history (from 01/01/19 - 03/10/22); incident reports (dated 11/20/20, 09/08/21, 10/13/21, 10/20/21, 11/18/21,12/08/21, 12/26/21, 01/20/22); behavioral contracts (dated 11/25/19 & 02/16/21); correspondence (dated 10/20/21 & 11/19/21) e-mailed to assisted-living waiver program social worker/supervisor, 30-Day Eviction Notice (dated 02/02/22), Summons Unlawful Detainer-Eviction (dated 03/10/22).

Allegation: Facility is not following COVID-19 guidelines:

The complaint alleges that Resident #1 had requested to be tested in its room on 11/23/21; and, it was done. On 12/01/21, Resident #1 requested to be tested (again) in its room; however, Administrator Fuentes advised that only the residents who cannot walk to the Activity Room (located on the first floor) will be tested in his/her room. At that time, Resident #1 was advised that if a resident is able to walk then the resident shall come to the Activity Room (located on the 1st floor) for his/her testing; otherwise, a resident can choose to go elsewhere to be tested at will. On 12/08/21, Resident #1 walked to the Activity Room (located on the 1st Floor) for its COVID testing. LPA/RA Ceniceros spoke with residents (R1-R7) in regards to testing in the Activity Room (located on the 1st Floor) rather than it their room; and, the majority residents stated that he/she has not had an issue with receiving his/her test by walking to the facility's Activity Room. LPA/RA Ceniceros spoke with facility staff (S1-S9); and, it was explained that the residents did not mind receiving his/her test in the facility's 1st floor Activity Room. Administrator Fuentes stated that when it first struck on or about October 2021, the residents were receiving tests in his/her room; however, since it was lifted on or about January 2022, residents returned to the facility's Activity Room (located on the 1st floor) to receive his/her test. Unless a resident couldn't walk, the contracted nurse would test the resident in his/her room. During LPA Cifuentes initial 10-Day visit on 12/21/21, it was observed that residents and facility staff were wearing his/her face mask and practicing social distancing. In addition, LPA/RA Ceniceros observed the residents and facility staff wearing his/her face mask during this visit.

Allegation: Resident is being illegally evicted:

The complaint alleges that while Resident #1 was receiving a test on 12/08/22 by the contracted nurse that

(Report continued on LIC 9099C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20211216155411

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: 03/10/2022

NARRATIVE

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Resident #1 was told that the facility was looking to evict the resident; as a result that the resident want to be tested in its room on 12/01/21; since it was done by the contracted nurse on 11/23/21. LPA/RA Ceniceros spoke with residents (R1-R7) in regards to having knowledge of a resident being evicted from the facility; and, the majority were unaware. LPA/RA Ceniceros spoke with facility staff (S1-S9) regarding a resident being evicted; and, the majority were unaware.

Allegation: Facility is retaliating against resident for making complaints:

The complaint alleges that Resident #1 is being treated differently by not being welcomed anymore and was followed by an eviction notice - believed to all be retaliatory in nature. LPA/RA Ceniceros spoke with residents (R1-R7) in regards to facility retaliating against him/her or another resident; and, the majority of these residents indicated that the facility has not used retaliating tactics against him/her or observed at another resident. LPA/RA Ceniceros spoke with facility staff (S1-S9) regarding facility retaliating against a resident; of which, he/she has not observed retaliation towards a resident.

Based on information gathered through interviews, observations, and records review, the Department did not find sufficient evidence to support the allegations mentioned above.

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 and a copy of this report was provided to Administrator Susana Fuentes.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

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