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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 05/27/2022
Date Signed: 05/27/2022 05:09:01 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
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/03/2022 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220303162611
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:
05/27/2022
UNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Susana FuentesTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident sustained burns while in care
INVESTIGATION FINDINGS:
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On 5/27/2022 at 12:52pm., Licensing Program Analyst (LPA)/Susan Campos, initiated a complaint investigation visit to deliver findings for the allegation listed above. LPA was allowed entry into the facility by Susana Fuentes, Administrator. LPA explained to Ms. Fuentes the purpose of the visit. On 3/4/22, the Department of Social Services Investigative Bureau, initiated a complaint investigation regarding “ Resident sustained burns while in care”. On 3/4/22, LPA and Ms. Fuentes conducted an inspection, for health and safety of the facilities’ physical plant, and food supply.


Report continued LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
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 2
Control Number 11-AS-20220303162611
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
MONTEREY PARK, CA 91754
FACILITY NAME: GARDENA RETIREMENT CENTER
FACILITY NUMBER: 197607366
VISIT DATE: 05/27/2022
NARRATIVE
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Investigation Revealed

Allegation: Resident sustained burns while in care

The Department of Social Service Investigative Bureau, Investigator Edward Hector, conducted interviews with R1, facility staff members, and also reviewed R1’s facility and medical documents. On 2/26/22, R1, Gardena Residential Center facility resident, suffered severe accidental burns, as a result of getting into a bathtub, with hot water temperature. R1, informed Investigator Hector, that R1 did not feel the temperature of the hot water due to R1’s medical condition. Also, Investigator Hector interviewed Gardena Residential Center facility staff, and they confirmed that R1 is independent, and does not use assistance to bathe self. In addition, Investigator Hector interviews, and record review confirmed that R1 does not use facility staff assistance to bathe self, and does not request staff services for assistance. R1 informed Investigator Hector that takes full responsibility for self-injury. Based on interviews and facility documents, R1 is independent and does not request services for bathing. Per Title 22, Division 6, Chapter 8, Article 8 CCR 87468.1(a)(16) Personal Rights of Residents in All Facilities, states: “Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services .“

Although the allegations may have happened or is 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 Susana Fuentes, Administrator, and a hard copy of a LIC 9099 was provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2