197607366-2-17-2022-11-AS-MVAO-CDVU9E-20220427152300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 02/17/2022
Date Signed: 02/17/2022 04:21:34 PM

Unsubstantiated

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
02/10/2022 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20220210144354

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: 68	DATE:	02/17/2022
		UNANNOUNCED	TIME BEGAN:	10:23 AM
MET WITH:	Susana Fuentes		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not administer medication to resident.

INVESTIGATION FINDINGS:

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On 2/17/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint investigation at the facility listed above. LPA spoke with staff Susana Fuentes via telephone call prior to entering the facility to conduct risk assessment questionnaire and was informed that facility had no COVID cases nor do any of the clients have symptoms. LPA arrived at facility and was greeted by staff. LPA explained the purposed of the visit was to investigate the allegation listed above and was granted access to the facility.

The investigation consisted of the following: LPA interviewed Administrator Susie Fuentes, five (5) staff (S1-S6) and six (6) residents (R1-R6). LPA inspected the facility. LPA reviewed resident records along with the current staff/resident roster and other documents in association with the allegation.

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: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

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-20220210144354

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: 02/17/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Staff did not administer medication to resident.

The complainant alleges that R1 had to call staff to receive their evening medication. LPA reviewed MAR for R1, which does not show any evening medications missed or refused for the month of February. LPA Cifuentes spoke to S1, who states R1 has not refused any evening medication while they have been on shift during the month of February, but that they did leave early on 2/9/2022 and left the medication for R1 ready to be given to them by the caregiver. LPA spoke with residents (R1-R6) regarding the allegation and 4 out of 6 stated staff had not failed to give them medications. One of the 6 declined to answer. LPA spoke with staff (S1-S5) regarding medications and 5 out of 5 stated facility staff never failed to give residents medications, with S1 adding that residents had refused their medications in the past..

Based on information gathered, the department did not find sufficient evidence to support allegation the allegation.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegation: " Staff did not administer medication to resident.”

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 hard copy of the report was provided to Susana Fuentes, Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC9099 (FAS) - (06/04)

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