197607366-5-31-2022-11-AS-MVAO-CFMLSB-20220622090029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 05/31/2022
Date Signed: 05/31/2022 03:44:02 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
01/03/2022 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20220103154748

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: 69	DATE:	05/31/2022
		UNANNOUNCED	TIME BEGAN:	02:53 PM
MET WITH:	Susana Fuentes		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff administered unprescribed medication to resident.
Facility has pests.

INVESTIGATION FINDINGS:

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On 5/31/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA called and spoke to administrator Susana Fuentes and was told the facility has no current COVID-19 cases nor do any of the staff or residents show any signs or symptoms. LPA arrived at facility and was greeted by Office Manager Christina Novoa. LPA explained the purposed of the visit was to investigate the allegations listed above and was granted entry.

The investigation consisted of the following:
On 1/5/2022 LPA Cifuentes spoke to facility administrator and reviewed facility records. LPA reviewed, requested and received the following documents: staff and client rosters, copies of MAR and pest control records. On 5/31/2022 LPA Cifuentes interviewed staff 1-staff 6 (S1-S6) and residents 1-resident 6 (R1-R6).
Continued on 9099-C

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: 05/31/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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-20220103154748

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: 05/31/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Staff administered unprescribed medication to resident.

It is alleged that facility staff gave resident a medication which was not prescribed by doctor. LPA reviewed MAR and medications and found no medications without prescription by doctor. LPA spoke with residents (R1-R6) regarding the allegation. LPA asked residents if they had ever received an unprescribed medication. Of those interviewed, 5 out of 6 stated that they had not been given a medication that was not prescribed to them, with a few adding that all their medications were prescribed by the doctor. LPA spoke with staff (S1-S6) regarding allegation. 6 out of 6 answered that residents are not given medications that are not prescribed.

Based on information gathered, the department did not find sufficient evidence to support allegation "Staff administered unprescribed medication to resident.”

Allegation: Facility has pests.

It is alleged that facility has bed bugs. On 1/3/2022 LPA Cifuentes inspected facility grounds and found no traces of bed bugs. LPA was given exterminator reports from Orkin dating from January 2022 to May 2022, as well as a few from late 2021 from both Orkin and Western Exterminators. No bedbugs were found in any of the reports. LPA interviewed residents regarding allegation and of the residents interviewed 6 out of 6 stated facility does not have bed bugs. LPA Cifuentes interviewed staff regarding allegation. Of the staff interviewed, 6 out of 6 stated facility does not have bed bugs.

Based on information gathered, the department did not find sufficient evidence to support allegation “Facility has pests.”

The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: “Staff administered unprescribed medication to resident, ” and “Facility has pests.”

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 hard copy 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: 05/31/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC9099 (FAS) - (06/04)

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