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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:57:51 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
03/17/2022 and conducted by Evaluator Jey Cardenas
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220317152343
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: 71DATE:
05/04/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Christina NovoaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident wandered from the facility.
Facility is not properly secured.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted a subsequent complaint visit to Gardena Retirement Center and continued investigation into the allegations listed above. Upon arrival at the facility LPA meet with Staff#1 (S1); LPA explained the reason for today’s visit and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection.

The investigation consisted of the following: Initial 10-day complaint visit was conducted on 3/22/22, LPA obtained a copy of resident and staff roster, interviewed Staff#1-Staff#7 (S1-S7) and Resident#1 -Resident#7 (R1-R7), Reviewed resident files, obtained copies of records relevant to the investigation, and tour the physical plant. On 5/4/22 LPA Cardenas conducted a tour of the physical plant.

It is alleged that on 3/17/22 the front desk was unmanned, consequently at approximately 9:00AM, R2 who has dementia left the facility unattended.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 11-AS-20220317152343
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: 05/04/2022
NARRATIVE
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(continued pg2)

-Regarding allegation: Facility is not properly secured. On 3/22/22 LPA reviewed the camera footage and observed that on 3/17/22 approximately 8:35am there wasn’t a staff at the front desk, nor was there staff around the area to supervise that dementia residents do not wander outside unsupervised. On 3/22/22 LPA interviewed administrator, Susana Fuentes and asked if there are auditory devices to notify staff when someone walks through the backdoor. Susana states that the facility is not a locked facility, and there are no alarms, however facility has an auditory device on exits. There’s a box located at the front desk, and when the backdoor is opened it will make a sound to notify staff. Staff will then review the camera to ensure its not a resident with dementia attempting to exit unassisted. On 3/22/22 at approximately 1:06pm LPA asked Susana to test the backdoor auditory devices, S1 opened the backdoor, however there was no alarm heard at the front desk. On 5/4/22 at approximately 9:31am LPA observed resident walk out the backdoor and LPA didn’t hear an auditory alarm go off to notify backdoor was opened. LPA asked S1 about the auditory device, in which she replied; the backdoor was replaced recently and the alarm was disabled. Facility is working to get the auditory device to work.
Based on LPA’s interviews, and record review(s), the preponderance of evidence standard has been met, therefore the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. Exit interview conducted and a copy of this report and appeal rights provided to facility representative.

-Regarding allegation: Resident wandered from the facility. Per Unusual incident report (UIR) dated 3/17/22; on 3/17/22 an outside pedestrian came to notify facility that resident was walking outside and was requesting to go to Torrance. S2 went out to check and determined that it was R2. Per Physician report R2 is diagnosed with Dementia and requires supervision to leave facility. Per Preplacement Appraisal dated 3/4/13 R1 has no sundowning, aggression, nor wandering behaviors. A reappraisal was not available at time of visit. On 3/22/22 LPA Cardenas reviewed the camera footage and observed that on 3/17/22 R2 walked out of the facility front entrance unassisted by a staff at approximately 8:35AM and was assisted back to the facility by staff at 9:03AM.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
03/17/2022 and conducted by Evaluator Jey Cardenas
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220317152343

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: 71DATE:
05/04/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Christina NovoaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
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8
9
Resident was spoken to in an inappropriate manner.
Resident's request for heat in their room was denied.
Resident was not allowed to install a television in their room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jey Cardenas conducted a subsequent complaint visit to Gardena Retirement Center to continued investigation into the allegations listed above. Upon arrival at the facility LPA meet with Staff#1 (S1); LPA explained the reason for today’s visit and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection.

The investigation consisted of the following: Initial 10-day complaint visit was conducted on 3/22/22, LPA obtained a copy of resident and staff roster, interviewed Staff#1-Staff#7 (S1-S7) and Resident#1 -Resident#7 (R1-R7), Reviewed resident files, obtained copies of records relevant to the investigation, and tour the physical plant. On 5/4/22 LPA Cardenas conducted a tour of the physical plant.

It is alleged that on 3/15/22 resident went to the office and told staff to turn up the temperature because the bedroom was cold. Residents hand was cold and wanted staff to feel it. S1 responded inappropriately and said, “I’m not going to touch your hand I don’t know where it’s been.” Resident was
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20220317152343
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: 05/04/2022
NARRATIVE
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told that the maintenance man would be notified, however the heater was not adjusted and the bedroom was 68 degrees. In addition, during a conversation with R3 it was brought up that administrator Susana didn’t allow R3 to install a television in the bedroom because a tv was already in that bedroom.

-Regarding allegation: Resident was spoken to in an inappropriate manner. On 3/22/22 LPA Cardenas interviewed R1-R7, of those interviewed five (5) indicated that staff do not speak to them in an inappropriate manner. R7 indicates facility is fine and refused to continue the interview. On On 3/22/22 LPA interviewed S1 who indicates that none of the residents have complained that staff are speaking to them inappropriately. Nor that none of the staff have reported witnessing other staff speak inappropriately to resident. S1 denies speaking inappropriately to a resident.

-Regarding allegation: Resident's request for heat in their room was denied. On 3/22/22 LPA interviewed S1 who indicates that thermometer temperature is automatically regulated. There are residents that feel facility is too cold, others feel its too hot, therefore temperature is kept in between to accommodate everyone. Temperature varies throughout the facility. S1 states that two weeks ago, a resident complained that their bedroom was too cold so S4 was asked to adjust temperature. On 3/22/22 LPA Cardenas interviewed S4 who indicates that one resident prefers room to be on the warmer side. A few days ago the thermometer read 78 degrees F and the resident complained that it was cold. Temperature is usually adjusted as needed per request; however other residents need to also be taken into consideration. On 3/22/22 LPA interviewed R1-R7, four (4) resident indicated that room is comfortable temperature and requests are responded appropriately. R2 states it was cold in the room once because a window was left open. R7 indicates facility is fine and refused to continue the interview. On 3/22/22 LPA Cardenas toured the facility in the AM and PM and noted temperature on the first and second floor (mid-points). LPA observed temperature was within title 22 regulations. On 5/4/22 LPA toured the facility in the AM and observed temperature was within title 22 regulations.

-Regarding allegation: Resident was not allowed to install a television in their room. On 3/22/22 LPA interviewed R1-R7. R3-R6 indicates that they are allowed to bring furnishings of their choice to their bedroom. R3 also confirmed being allowed to install a television in the bedroom. However, it took a few days because the wifi needed to be hooked up. R7 indicates facility is fine and refused to continue the interview. On 3/22/22 LPA Cardenas interviewed administrator, Susana who indicates that resident bedrooms are furnished upon mo

“Although the allegation may have happened or is valid, there is ving in. However, residents are allowed to bring in any furnishing of their choice. They can decorate the walls with pictures to their liking. Facility generally won’t provide a tv, but if residents need a tv facility has donations that residents can have. not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.” Exit interview conducted and a copy of this report was provided to facility representative.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20220317152343
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: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2022
Section Cited
CCR
87705(j)
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The licensee shall have an auditory device or other staff alert feature to monitor exits... This requirement not met as evidenced by: On 3/22/22 and 5/4/22 LPA observed backdoor was opened and auditory device was inoperable. This poses immediate risk to residents in care.
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Facility will submit in writing plan with timelines to ensure that exits have auditory devices.
Type B
05/06/2022
Section Cited
CCR
87463(a)
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The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes...This requirement not met as evidenced by: On 3/22/22 LPA didn't observe a reappraisal for R2 after wandering behavior. This poses a potential health and safety risk to resident.
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Facility will ensure that R2 has a reappraisal on file and will submit document to LPA via email.
Type B
05/06/2022
Section Cited
CCR
87705(b)(2)
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Safety measures to address behaviors such as wandering, aggressive behavior...This requirement not met as evidence by: On 3/22/22 LPA observed that R2 exited the facility unassited by staff, there was no staff monitoring exits. This poses a potential health and safety risk to residents.
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Facility will outline plan with safety measures to address wandering behavior. Ensure all staff receive and understand plan. Submit plan to LPA by email.
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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: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey CardenasTELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5