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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 06/16/2022
Date Signed: 06/16/2022 04:15:08 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
06/08/2022 and conducted by Evaluator Susan Campos
COMPLAINT CONTROL NUMBER: 11-AS-20220608152646
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: 68DATE:
06/16/2022
UNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Susana FuentesTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility is not following COVID-19 protocols.
INVESTIGATION FINDINGS:
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On 6/16/22 at 12:19 pm, Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by Administrator Susana Fuentes. LPA explained to Ms. Fuentes the purpose of the visit. The investigation consisted of the following: LPA conducted interviews on 6/16/22 with (4) staff members, and (6) facility residents. In addition, on 6/16/22, the LPA and Ms. Fuentes conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. The LPA also reviewed the following documents provided by Administrator Susana Fuentes from the Gardena Retirement Center: LIC 500-Staff Roster, Client Roster, Facility Mitigation Plan, and House Rules.

Report continued on 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: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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-20220608152646
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: 06/16/2022
NARRATIVE
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Investigation

Allegation: Facility is not following COVID-19 protocols.

The investigation revealed, per LPA interviews, with (4) staff members, (6) residents from the Gardena Residential Center facility, and also review of facility documents, that the facility follows COVID-19 protocols. S1 informed the LPA, that the facility follows COVID-19 protocols, and specifically follows the facility mitigation plan. S1 also informed the LPA, that there is COVID testing weekly for staff and residents. In addition, S1 stated that the facility staff encourage the residents to use face masks inside and outside the facility. LPA conducted an inspection and observed that the facility is following its mitigation plan measures. The LPA also interviewed (4) facility staff personnel, and 4 of the 4 staff personnel interviewed, informed the LPA that they have been trained in COVID protocol procedures, and also, that the staff encourage residents to wear face masks in the facility, and to wear face masks outside the facility. In addition, the LPA interviewed (6) residents, and 6 of 6 residents interviewed, informed the LPA, that the facility staff follow COVID-19 procedures when there are positive cases in the facility. Also, the LPA interviewed (6) residents, and 6 of 6 residents interviewed, informed the LPA, that the facility staff provide them with face masks, to use inside and outside the facility. Furthermore, during the LPA interviews, 6 residents, informed the LPA that the facility staff assist them with their care needs, and also, 6 of 6 residents interviewed, informed the LPA, that staff are available to them when needed.

Based on information gathered, the LPA did not find sufficient evidence to support allegation " Facility is not following COVID-19 protocols. ”

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: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2