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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 03/21/2022
Date Signed: 03/21/2022 04:43:46 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
12/23/2021 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211223090835
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: 72DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Susana FuentesTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility has inadequate staffing.
Facility does not provide activites for residents.
INVESTIGATION FINDINGS:
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On 03/21/22, Licensing Program Analyst (LPA/RA) Elizabeth Ceniceros conducted an unannounced subsequent visit to the facility at 8:00 a.m. LPA/RA spoke to Staff #1 (S1: Elizabeth Chavez, Med Tech-AM) prior to entering the facility to conduct a risk assessment. Staff #1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA/RA was later met by Administrator (A1) Susana Fuentes at 9:30 a.m. and explained the purpose of today’s visit was to investigate the above-mentioned allegations.

The investigation consisted of the following: Licensing Program Analyst (LPA) Stephanie Cifuentes conducted the unannounced initial 10-Day complaint investigation on 12/29/21. LPA/RA Ceniceros interviewed Administrator, seven (7) staff members (S1-S7), and eight (8) residents (R1-R8). During the course of this investigation, LPA/RA toured the facility grounds and interviewed facility staff members and residents; reviewed facility records (residents roster, facility staff roster and staff work schedules).

(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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 3
Control Number 11-AS-20211223090835
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: 03/21/2022
NARRATIVE
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Allegation: Facility has inadequate staffing:

The complainant reported that facility is not providing enough care for dementia residents as well as other residents. Facility is admitting more dementia residents and the problems increase because they are using the Activity Room (1st floor) as a day care center; and, there’s an average of 10 – 14 residents and one (1) staff member watching them. LPA/RA Ceniceros spoke to Administrator Fuentes who replied, in the past, whenever the facility was going to be short staff, they would contract with a health care staffing agency to fill the vacancy on a temporary basis - until a new staff member is hired on board. Recently, the facility hired three (3) additional staff members: caregiver, housekeeper, and an activities coordinator. LPA/RA interviewed seven (7) residents; and, the majority agreed that the facility has adequate staffing to meet his/her needs. LPA/RA interviewed six (6) staff members (S1-S6); and, the majority agreed that the facility has sufficient staffing to meet the needs of the residents. LPA/RA reviewed the facility’s residents’ roster, facility staff roster and staff work schedules (week of 11/28/21 thru 12/25/21 and current); and, the facility has sufficient staffing.


Based on information gathered through interviews and observations and records review, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated.

The investigation consisted of the following: LPA/RA Ceniceros interviewed Administrator, six (6) staff members (S1-S6) and seven (7) residents (R1-R7). During the course of this investigation, LPA/RA toured the facility’s activity rooms (located on the 1st and 2nd floors); reviewed facility records: staff roster, residents roster, activities calendars (December 2021 – March 2022); observed current posted monthly activity calendar (posted on the board by the main entrance) and residents participating in the A.M. and P.M. activities.

Allegation: Facility does not provide activities for residents:

The complaint alleges that the facility does not provide activities for residents. LPA/RA Ceniceros toured the activity room and observed (approx) 16 residents participating in the morning activity (exercise) at 10:35 a.m. and approximately 12 residents participating in the afternoon activity (music choice) at 1:20 p.m.

(Report continued on LIC 9099C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20211223090835
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: 03/21/2022
NARRATIVE
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LPA/RA Ceniceros observed the posted March 2022 Activity Calendar (photo) and reviewed past monthly activity calendars (December 2021 – March 2022). LPA/RA interviewed residents (R1-R7) regarding activities provided at the facility; and, the majority indicated that because of COVID some of their activities where stopped; however, now that COVID has been lifted, the facility is providing in-person activities; such as: arts & crafts, movie, bingo, board games, music choice, kareoke, and exercise; but, soon they’ll be doing outings into the community (i.e., park, shopping, theatre and/or restaurant).

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



Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegation is unsubstantiated.

An exit interview was conducted and a copy of this report was provided to Administrator Susana Fuentes.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3