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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607366
Report Date: 06/08/2021
Date Signed: 06/08/2021 01:52:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
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: 64DATE:
06/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Alejandra GuzmanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst(LPA) Stephanie Cifuentes conducted an unannounced a case management visit regarding an incident reported to CCL on 6/4/2021. LPA Cifuentes explained the purpose of the visit to the facilities administrator Alejandra Guzman and was granted access.

During today's visit LPA interviewed administrator, staff, and residents.

LPA requested and received full files for resident 1 and resident 2 as well as full file for staff 1.

No deficiencies will be cited at this time, additional investigation is required which includes analysis of the records obtained and follow-up interviews

Exit interview held and a copy of report provided to administrator.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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