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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607366
Report Date: 05/19/2022
Date Signed: 05/19/2022 05:08:19 PM


Document Has Been Signed on 05/19/2022 05:08 PM - It Cannot Be Edited

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
MONTEREY PARK, CA 91754



FACILITY NAME:GARDENA RETIREMENT CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:SUSANA FUENTESFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: 69DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Susana FuentesTIME COMPLETED:
05:00 PM
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On 05/19/22, Licensing Program Analysts (LPA) Gail Johnson conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Johnson met with the Administrator Susana Fuentes. LPA Johnson explained the purpose of today’s visit. The facility is licensed to operate 108 non-ambulatory residents 60 years and above.

Facility Structure
The facility is a two-story building located in a residential neighborhood. It consists of the following: Administrator’s office, front office, medication room, dining room, two activity rooms, kitchen, laundry room, patio, shaded area, indoor and outdoor activity areas, and storage room.

Physical Plant
LPA Johnson toured the physical plant. There were no bodies of water or obstructions on the premises. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.8 degrees F.

Storage & Inaccessible Items


Storage areas for cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and found as clean and in adequate condition. Nine (9) fire extinguishers were fully charged. Smoke detectors and carbon monoxide detectors were operable.

Continued on LIC 809-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/19/2022
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Activities Calendar: LPA Johnson observed a bulletin board in the hallway that displayed various activities. The activities listed on the bulletin board included: movies, arts and crafts, outdoor outings, games and exercising. Pool/Jacuzzi & Pets: LPA's did not observe any pet or bodies of water at the facility. Fire Inspection was approved on 02/08/2022.

Infection Control
During the visit, LPA Johnson observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. Sanitizing stations in common areas and restrooms. LPA Johnson observed staff was wearing face coverings. LPA observed the facility has a 60-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file. Deficiencies were not identified during this annual inspection visit.

An exit interview was conducted with Susana Fuentes. A copy of this report was printed and provided to Susana Fuentes.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC809 (FAS) - (06/04)
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