197607366-3-8-2022-11-AS-EMAZ-CDAUTS-20220408155224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 03/08/2022
Date Signed: 03/08/2022 05:15:38 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
01/31/2022 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20220131144606

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: 72	DATE:	03/08/2022
		UNANNOUNCED	TIME BEGAN:	02:27 PM
MET WITH:			TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility do not provide transportation to medical appointments.
Resident was injured in while in care.
Staff did not provide adequate services to resident in care.

INVESTIGATION FINDINGS:

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On 3/8/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint visit at this facility. LPA spoke with Administrator Susana Fuentes via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to deliver findings on the allegations listed above.

The investigation consisted of the following: On 2/4/2022 LPA conducted a tour of facility grounds and reviewed records for staff and residents. LPA conducted interviews with (6) staff members (S1-S6), and (6) residents (R1-R6). LPA Cifuentes requested and received the following documents: Client roster, staff schedule, shower schedule and other documents in relation to the investigation.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

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-20220131144606

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: 03/08/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Facility do not provide transportation to medical appointments.

The complainant alleges that facility told them transportation could not be provided for R1 to doctor’s appointment. Per Administrator Susie Fuentes, facility does not have a van to provide transportation, but they do assist residents in setting up their transportation, whether that is Lyft, Uber or whatever medical arrangements need to be made. LPA Cifuentes spoke to staff 1 (S1) who stated R1 and their children usually handled their medical transportation, but that recently R1’s family called facility asked them if they could help schedule transportation to a medical appointment. Per S1, they called several insurance companies and the doctor, then later received a call from the family at the end of the day stating they had already arranged the medical transportation. S2 added that family requested a second transportation appointment, which facility arranged for them, but family then wanted to cancel. LPA spoke to R1, who stated family arranged medical transport for them. LPA Cifuentes interviewed residents (R1-R6) regarding transportation to medical appointments. Two stated they handled transportation themselves, two stated family handled transportation, one stated their doctor came to the facility and the last stated they did not know. LPA interviewed staff (S1-S6) transportation to medical appointments. Three put of the six stated that facility assisted with transportation, two stated they were not sure one refused to answer.

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

Allegation: Resident was injured in while in care.

The complainant alleges that R1 was bitten by bugs while at facility, which caused a skin infection and hospitalization. LPA Cifuentes reviewed incident reports from last year, and found one report stating that R1 was hospitalized, but not from an incident that cause an injury. LPA also reviewed pest control reports from that time period and found no reports of bedbugs in the facility over the past several months. LPA spoke to R1 regarding an injury sustained while in care. Per R1, a friend fell on their leg, but they did not mention a skin infection. LPA spoke with residents (R2-R6) regarding the allegations. Of those interviewed, five out of five stated they had not been injured while in care. LPA Cifuentes interviewed staff (S1-S6) regarding residents being injured while in care. Out of those interviewed, six out of six reported that residents had not been injured while in care.

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 Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220131144606

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: 03/08/2022

NARRATIVE

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Allegation: Staff did not provide adequate services to resident in care.

The complainant alleges that R1 is not receiving baths/showers. LPA spoke to administrator Susie Fuentes regarding allegation. Administrator Fuentes stated facility has a shower schedule and she has not received any complaints about someone not being showered, not receiving assistance with ADL’s or not being groomed. LPA interviewed residents (R1-R6) about the services they ae receiving. Of those interviewed, four out of six residents stated they handle their ADL’s on their own, one stated staff assisted them and one stated no one helped them and they needed assistance. LPA interviewed staff (S1-S6) about services provided to residents. Six out of six staff stated they provided residents with assistance bathing and grooming.

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 records, incident reports, and interviews conducted and found no evidence to support the allegations.

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 hard copy of the report was provided

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC9099 (FAS) - (06/04)

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