197607366-4-12-2022-11-AS-MVAO-CDWTT4-20220428150008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:30:22 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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220411152451

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: 71	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	SUSANA FUENTES		TIME COMPLETED:	02:59 PM

ALLEGATION(S):

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Facility staff is not adequately supervising residents in care.

INVESTIGATION FINDINGS:

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On 04/12/22 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility. LPA met with administrator Susana Fuentes and explained the purpose of today's visit is to gather information for the allegation mentioned above.

The investigation consisted of the following: LPA inquired about questions relevant to the nature of the complaint. Interviews with staff #1- #5 (S1-S5), residents #1-#4 (R1-R4), and witness #1 (W1). A copy of resident #1 (R1) physician report and medication administration record, and other pertinent documents related to the allegation. An observation assessment video surveillance footage from 04/10/22. An inspection of the facility was conducted.

Evaluation Report continues on LIC 9099

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220411152451

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: 04/12/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility staff is not adequately supervising residents in care.

The details of the complaint state the facility failed to adequately supervise resident #1 (R1) in care. The complainant claims a staff member's four-year-old child was allowed in the facility on 04/10/22 unsupervised. The complainant claims the child was allowed to push (R1) around in his wheelchair unattended and that staff member (S2) was aware and did nothing to control the situation. An observation assessment of the facilities’ video surveillance footage from 04/10/22, verified the child was allowed to run around the hallways and common areas unaccompanied. The video footage also uncovered the child was in motion pushing (R1’s) wheelchair in the lobby and playing around and handling the medication cart. Several residents were featured in the video footage resident #1-#3 (R1-R3) confirmed a child was present at the facility on 04/10/22 and had seen the child hold (R1’s) wheelchair unattended by staff. (R4) who was also featured in the video declined to be interviewed. Interview with (R1) acknowledged the child had wheeled him around in his wheelchair about 50 feet from the dining room to the lobby unsupervised and unaccompanied. (R1) claims he could control his directions from his sides, however, did not have control from the rear when being pulled back and forth as he was unable to see from behind. Witness #1 (W1) confirmed a child was pushing (R1) around, and that no staff managed to supervise. Interviews with staff #1-#2 (S1-S2) admitted the child was present and had contact with (R1) while he was in his wheelchair. (S1) claims due to unforeseen family circumstances the child was at the facility for a longer stay than she had anticipated and takes full accountability for her actions. (S5) was made aware of the incident and reviewed the video surveillance footage with the Department where it displayed the child was allowed to have access to the common areas unaccompanied or unsupervised by staff. Based on information gathered, interviews, service records, and surveillance video footage reviewed, there is sufficient evidence to corroborate the allegation mentioned above.

Based on the Department's observation, interviews, records, and video footage reviewed, the preponderance of evidence standard has been met, therefore the allegation of " Facility staff is not adequately supervising residents in care" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220411152451

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/26/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee will review Title 22 Section 87468.1 and shall provide staff with training on supervision observation of the residents. Licensee will provide copies of training materials and sign-in sheet to CCL by POC 04/26/22 due date.
	8 9 10 11 12 13 14	Based on observation, interviews, and record reviews (R1) was not accorded a safe environment when staff allowed a child to roam unattended/unsupervised. This violation poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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