197607366-3-8-2022-11-AS-MVAO-CDVUKY-20220427153956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 03/08/2022
Date Signed: 03/08/2022 05:16:55 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
02/28/2022 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20220228091331

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:	03/08/2022
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Susie Fuentes		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility has a leaking pipe

INVESTIGATION FINDINGS:

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On 3/8/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced complaint investigation at the facility listed above. LPA spoke with Administrator Susana Fuentes via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit was to investigate the allegations listed above and was granted access to the facility.

The investigation consisted of the following: LPA Cifuentes conducted a tour of facility grounds. LPA spoke with administrator, reviewed facility files and interviewed staff 1 -Staff 6 (S1-S6) and Residents 1-resident 6 (R1-R6). LPA also received staff roster, resident roster, invoice for plumbing repair.

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: 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)

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Control Number 11-AS-20220228091331

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: 03/08/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Facility has a leaking pipe

The complainant alleges that a pipe at the facility, which runs to out to the back of the facility grounds, was leaking feces. LPA Cifuentes toured the outside of facility and saw no broken or uncovered pipes, LPA did however find a red pipe stopper covering one of the pipes leading out of the building. LPA Cifuentes received a copy of invoice for Live Plumbing Sewer and Drains, which confirms work was done at the facility on 3/3/2022. LPA called and spoke to Hugo from Live Plumbing Sewer and Drains, who confirmed the that he snaked the line and pulled paper towels, tree roots and face masks from the sewage line and replaced the cap on the pipe. LPA Cifuentes spoke with administrator Susie Fuentes, who stated that a pipe at the facility did not leak, the stopper for one of the pipes outside popped off. The plumber was called immediately, and the matter was taken care of that day. LPA interviewed residents (R1-R6) regarding leaking pipe. Of the residents interviewed, four out of six stated that they were not aware of any leaking pipes, and six out of six stated there are no issues with the facilities plumbing. LPA interviewed staff (S1-S6) regarding leaking pipes. Of those interviewed, two out of six staff stated there was a leaking pipe at the facility and four out of six stated they had head about an issue with the plumbing.

Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R-1)'s service records, incident report, and interviews conducted and found no evidence to support the allegations.

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 with Susie Fuentes and a copy of the report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
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)

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