197607366-4-6-2022-11-AS-AJKK-CDDUSU-20220411155055

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 03/25/2022
Date Signed: 04/06/2022 10:20:02 AM

Substantiated

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
03/15/2022 and conducted by Evaluator Ngozi Nwaokoro

COMPLAINT CONTROL NUMBER: 11-AS-20220315164036

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:	03/25/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Susana Fuentes		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Mat/rug is in disrepair.

INVESTIGATION FINDINGS:

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On 3/25/2022 Licensing Program Analyst (LPA) Ngozi Nwaokoro initiated a subsequent complaint investigation visit for the allegations listed above. LPA spoke with Administrator Susana Fuentes via telephone prior to entering the facility to conduct a risk assessment and was informed that facility has no COVID-19 cases nor do any of the residents have symptoms. LPA arrived at facility and explained the purposed of the visit is to deliver findings on the allegations listed above.

Investigation consisted of the following: On 3/22/2022 LPA Jey Cardenas and LPA Ngozi Nwaokoro conducted an initial 10-day visit to gather information for the allegations listed above. LPAs met with administrator Susana Fuentes. LPAs obtained a copy of the current resident and staff roster, interviewed Staff#1-Staff#7 and Resident#1 -Resident#7, reviewed resident files and obtained copies of records relevant to the investigation. LPAs toured the physical plant.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Ngozi Nwaokoro	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

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-20220315164036

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: 03/25/2022

NARRATIVE

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Investigation revealed the following:

The complaint alleges that a mat/rug was in disrepair. According to the complainant, there is a rubber floor mat with curled up edges located in front of the glass doors that exit to the garden. It is next to the vending machine. During the physical plant walkthrough, LPA Nwaokoro observed the mat that was in disrepair. The mat had curled up edges that could possibly be a tripping hazard. LPA Nwaokoro took a picture of the mat. During the investigation with maintenance manager, he informs LPA that he overhead our discussion with the administrator and had to remove the mat from in front of the glass doors that exit to the garden. Before existing the facility, LPA observed the mat was removed.

Staff 1 -7 (S1 – S7) were interviewed and revealed the following: S1 stated that when S1 is notified about a maintenance need S1 logs it in the book and notifies maintenance. S1 stated they were notified by R1 of the mat. S1, S2, S5, and S7 stated they were not aware of any falls regarding a mat. S2 – S7 stated that maintenance is responsive to the needs of the facility. S3 was not aware of the disrepair mat but when S3 saw the LPAs in the facility they inquired about the purpose of their visit and was informed it was about a mat; S3 removed the mat. S5 stated that they have seen the mat used as a doorstopper. S4, S5, and S7 did not see the disrepair mat. S6 stated that the med cart got caught on it once but did not report it to management.

Residents 1 – 7 (R1 – R7) were interviewed and revealed the following: R1 stated that the facility is not responsive to maintenance. R1 reported the disrepair mat to S1 in February 2022. S1 stated they will tell maintenance. When R1 noticed nothing was done R1 reported it to Licensing. However, on 3/22/2022 R1 realized the mat was removed. R5 thinks the facility is responsive. R6 stated that they do not pay attention the things going on in the facility. When asked if they noticed the mat in disrepair R2 was not able to answer, and R4 stated they mind their own business. R7 did not see a disrepair mat. When asked if they like the facility R3 said they like the facility and wanted to leave and play a game. R6 does not like the facility, and R7 is not satisfied with the facility. R7 stated that the staff talk about residents in the hallway. The administrator prefers some residents over others.

Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Susana Fuentes, Administrator and a hard copy of a LIC 9099 and LIC 9099D was provided

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Ngozi Nwaokoro	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20220315164036

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/25/2022 Section Cited CCR 80087	1 2 3 4 5 6 7	Building and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidence by: LPA observed a mat in disrepair in front of the glass doors that lead out to the garden.	1 2 3 4 5 6 7	Administrator will remove the disrepair mat/rug and replace it with one that do not pose hazards or led to residents fall.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Ngozi Nwaokoro	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022

LIC9099 (FAS) - (06/04)

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