197607366-5-12-2022-11-AS-EMAZ-CGS2LF-20220728172927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 05/12/2022
Date Signed: 05/12/2022 05:19:40 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
05/04/2022 and conducted by Evaluator Gail Johnson

COMPLAINT CONTROL NUMBER: 11-AS-20220504155701

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: 71	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	08:34 AM
MET WITH:	Susana Fuentes		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff speaks inappropriately of residents.

INVESTIGATION FINDINGS:

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On 05/11/22, Licensing Program Analyst (LPA) Gail Johnson and Licensing Program Manager (LPM) Eva Alvarez conducted an unnanounced complaint investigation. LPA Johnson and LPM Alvarez met with Administrator Susana Fuentes and explained the purpose of today's visit.

Investigation consisted of: LPA Johnson conducted interviews with Administrator Fuentes, Staff (S1) – (S3) and Residents (R1) - (R7). LPA Johnson obtained copies of the staff training on 03/10/22 in recognizing residents’ needs and communication and expectations, and Personal Resident Rights training dated 04/14/22, Staff roster, and client roster.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail Johnson	TELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20220504155701

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: 05/12/2022

NARRATIVE

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Investigation revealed:

Allegation- Staff speak inappropriately to residents.

On 05/11/22 and 05/12/22, LPA Johnson obtained relevant documents, interviewed Administrator, Staff (S1)-(S3) and Residents (R1)-(R7). LPA was unable to verify that “Staff speak inappropriately to or about residents.” LPA conducted interviews with (S1)-(S2) and stated that, they have not spoken inappropriately to or about residents. LPA conducted interviews with (R1) ,who stated that Staff communication is “friendly and helpful.” LPA did not find sufficient evidence to support allegation above.

Although the allegation 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. A copy of this report was given to Administrator Susana Fuentes.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail Johnson	TELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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