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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 03/08/2022
Date Signed: 03/08/2022 05:12:10 PM

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
10/05/2021 and conducted by Evaluator Elizabeth Ceniceros
COMPLAINT CONTROL NUMBER: 11-AS-20211005161649
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: 72DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Suzanna FuentesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident harassing another resident at facility.
INVESTIGATION FINDINGS:
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On 03/08/22 at 8:07 a.m. Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros, conducted an unannounced subsequent complaint investigation visit regarding the above-mentioned allegation. LPA Stephanie Cifuentes conducted the initial 10-Day visit on 10/07/21. LPA Cifuentes spoke with Administrator Suzanna Fuentes (via telephone) prior to entering the facility to conduct risk assessment questionnaire; and, she was informed that facility had no COVID cases nor do any of the residents have symptoms. LPA/RA was allowed entry into the facility by Staff #1 (Office Manager, Cynthia LN). LPA/RA was later met by Administrator (Suzanna Fuentes) at 9:05 a.m. and explained the purpose of today's visit.

The investigation consisted of the following (related to Complaint Control Number: 11-AS-20211004115959): LPA Cifuentes on 10/19/21 interviewed Administrator Suzanna Fuentes, six (6) staff members (S1-S6), six (6) residents (R1-R6), reviewed residents records (R1-R6), current staff members & residents rosters, and incident reports (dated 03/02/21, 03/03/21).

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

DATE: 03/08/2022
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 6
Control Number 11-AS-20211005161649
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: 03/08/2022
NARRATIVE
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Allegation: Resident harassing another resident at facility:

The complainant alleges that R1 is being harassed by R2. On September 11, 2021 LPA Cifuentes received witness statements stating R2 was calling several residents names and making derogatory remarks towards them. On 10/04/21, LPA Cifuentes received a faxed incident report documenting an incident of aggression between R1 and R2. LPA viewed a video of the incident between R1 and R2. LPA spoke with residents (R1-R6) regarding harassment and 4 out of 6 stated they had witnessed harassment between residents. LPA spoke with staff (S1-S6) regarding harassment between residents and 4 out of 6 staff stated that they had witnessed harassment between residents.

Based on the information gathered, the department did find sufficient evidence to support the allegation of"Resident harassing another resident at facility".

Based on interviews conducted and records reviewed the preponderance of evidence standard has been met; therefore, the above-mentiond allegation is 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 and a copy of the LIC 9099 and appeal rights forms were provided to Administrator Suzanna Fuentes.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
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)
Page: 2 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
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2021 and conducted by Evaluator Elizabeth Ceniceros
COMPLAINT CONTROL NUMBER: 11-AS-20211005161649

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:
03/08/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Suzanna FuentesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility retaining residents that require a higher level of care
Facility staff are restraining resident(s) in care
Residents are not being provided activities while in care
Staff do not answer the facility phones.
Staff do not respond to resident(s) call buttons.
INVESTIGATION FINDINGS:
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On 03/08/22 at 8:07 a.m. Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros, conducted an unannounced subsequent visit regarding the above-mentioned allegations. LPA Stephanie Cifuentes conducted the initial 10-Day visit on 10/07/21. LPA Cifuentes spoke with Administrator Suzanna Fuentes (via telephone) prior to entering the facility to conduct risk assessment questionnaire; and, she was informed that facility had no COVID cases nor do any of the residents have symptoms. LPA/RA was allowed entry into the facility by Staff #1 (Office Manager, Christina Novoa). LPA/RA was later met by Administrator (Suzanna Fuentes) at 9:05 a.m. and explained the purpose of today's visit.

The investigation consisted of the following: LPA/RA conducted interviews with (4) staff members and (6) residents. LPA/RA and Ms. Fuentes conducted an inspection of the facilities’ physical plant; inspection of (6) facility resident rooms to test the call button box signal into the main station and front desk response time.

(Report continued on LIC 9099C)
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: 03/08/2022
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: 3 of 6
Control Number 11-AS-20211005161649
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: 03/08/2022
NARRATIVE
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LPA/RA Ceniceros reviewed additional documents provided by Administrator Fuentes: staff roster, client roster, staff schedule, activity schedule calendars (October 2021 to present), Admission Agreements for R1-R2, Physician's Reports for R1-R2, Appraisal/Needs & Services Plan for R1-R2, I.D. and Emergency Information for R1-R2, activities calendar schedule (October '21 - March '22); observed residents during A.M. and P.M. activities.

Allegation: Facility retaining residents that require a higher level of care:

The complaint alleges that Administrator is admitting residents that require a higher level of care and not meeting the needs of residents in assisted living. LPA/RA Ceniceros spoke with residents (R1-R9) regarding their needs being met by facility staff and the majority residents agreed that their needs are being met by facility staff in assisted living. Administrator Fuentes confirmed their current census is 72 residents and currently their are approximately ten (10) dementia resident. LPA/RA Ceniceros spoke with facility staff (S1-S6) regarding residents needs being met and 6 out of 6 facility staff say that they have not received complaints from assisted-living residents regarding their needs not being met.

Allegation: Facility staff are restraining resident(s) in care:

The complaint alleges that Resident #7 is very active and loves to engage in artistic activities; which the resident can't do now; and, the staff are not able to handle the care needs of the dementia residents. LPA/RA Ceniceros spoke with residents (R1-R9) regarding their needs being met by facility staff and the majority assisted-living residents agreed that their needs are being met by facility staff and have not witnessed facility staff restraining residents in care. Administrator Fuentes confirmed their current census are 72 residents and there are approximately ten (10) dementia residents. LPA/RA Ceniceros spoke with facility staff (S1-S6) and the majority deny that facility staff are restraining dementia residents.

Allegation: Residents are not being provided activities while in care:

The complaint alleges that residents are not being provided activities while in care. LPA/RA Ceniceros toured the activities room and observed approximately 15 residents participating in activity in the morning 10:15 a.m. watching a movie and afternoon at 1:20 p.m. playing Bingo. LPA/RA observed the posted March 2022 Activity Calendar (photo). LPA/RA reviewed the past monthly activity calendars (October 2021 - current).

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
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)
Page: 4 of 6
Control Number 11-AS-20211005161649
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: 03/08/2022
NARRATIVE
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 LPA/RA Ceniceros spoke with residents (R1-R9) regarding the 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 activities; such as, Arts & Crafts, Movie, Bingo, Music, Kareoke, Exercise, and their outings into the community.)

Allegation: Staff do not answer the facility phones:

The complaint alleges that facility staff do not answer the facility phones. LPA/RA called the facility by pressing the outside call button - prior to arrival at 8:00 a.m. and someone answered the phone. LPA/RA observed facility staff seated at the front desk at all times during this visit and answering incoming calls. LPA/RA spoke with random residents (R1-R9) who indicated that whenever they've called the facility's front desk (via cell) that his/her call was being answered by facility staff.

Allegation: Staff do not respond to resident(s) call buttons:

The complaint alleges that when residents use their call buttons to summons facility staff that their calls are not answered in a timely manner. LPA/RA randomly toured eight (8) residents rooms and tested the call button box in Rooms #11, 17, 19, 20, 30, 36, 38, 47; and, LPA/RA observed the front desk answer the call in a timely manner. LPA/RA inspected the computerized call button main station (video) and observed its operation. LPA/RA spoke with residents (R1-R9) regarding their calls being answered in a timely manner by facility staff and the majority agreed that there wasn't an issue with their call button box being answered in a timely manner. LPA/RA spoke with facility staff (S1-S6) and the majority agreed that facility staff man the call button main station 24/7 by facility staff working the morning, afternoon or graveyard shift.

Based on information gathered through interviews, observations, and records review, the Department did not find sufficient evidence to support the allegation 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 Suzanna Fuentes.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
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)
Page: 5 of 6
Control Number 11-AS-20211005161649
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: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2022
Section Cited
CCR
87468.1(a)(3)
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Personal RIghts of Residents All Facilities
To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
This requirement was not met as evidenced by:
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Administrator will submit a plan to LPA/RA Ceniceros on how they will prevent any resident-on-resident harassment in the future and submit to LPA/RA by POC due date on 03/22/2022.
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Based on LPA/RA Cifuentes on 10/19/21 observations and interviews, the facility did not insure residents in the facility were free from intimidation or abuse. This poses a potential Health & Safety 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6