197607366-7-26-2022-11-AS-EMAZ-CHW3U6-20220902183301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 05/19/2022
Date Signed: 07/26/2022 01:37:40 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

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220504104523

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:	05/19/2022
		UNANNOUNCED	TIME BEGAN:	09:53 AM
MET WITH:	Susana Fuentes		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident is being financially abused while in care.

INVESTIGATION FINDINGS:

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This report serves as an ammendment to correct the report creation date and the date of visit. It does not supersede the complaint investigation finding reflected on the report created on 05/19/22. On 05/19/22, Licensing Program Analyst (LPA) Gail Johnson and Licensing Program Manager (LPM) Eva Alvarez conducted a subsequent complaint visit. 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 (R1)’s Physician’s Report, (R1)’s Appraisal/Needs and Services Plan, (R1)’s Trust Transaction History (dated January 1, 2018 – January 12, 2022), written correspondence (dated 01/12/2022) to (R1) from facility communicating discontinuing management of (R1)’s account, facility issued reimbursement check for the balance of R1’s Trust Account (dated January 12, 2022), facility Trust Fund Agreement terms, as well as current rosters for Staff and Residents.
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: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

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 3

Control Number 11-AS-20220504104523

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: 05/19/2022

NARRATIVE

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Investigation revealed:

Allegation - Resident is being financially abused while in care.

During interviews conducted, Resident (R1) stated the facility did not clearly explain the history of R1’s Trust Fund account transactions and this caused confusion. R1 stated the facility did not explain transaction history and R1 believed there were account balance discrepancies. R1 stated he found no discrepancies after reviewing his account statements recently. R1 stated when his Trust Fund account was active, he received his check, signed the check, and endorsed it to the facility for deposit. R1 would then withdraw funds from this account. LPA Johnson and LPM Alvarez conducted an interview with Administrator Fuentes, who stated R1 has made multiple accusations of the facility mismanaging R1’s account. The facility made a decision to no longer manage R1’s Trust Fund as of 1/12/2022. R1 was issued a check for the Trust Fund account remaining balance. Administrator Fuentes notified R1 of discontinuing management of R1’s Trust Fund in writing and verbally on 1/12/2022. As of 5/17/2022, R1 has not agreed to receive the check issued from the facility for the Trust Fund account balance. Administrator Fuentes stated all Residents with Trust Funds sign out funds and receive receipts when funds are dispersed. Administrator Fuentes states the facility maintains copies of receipts on record. LPA Johnson and LPM Alvarez conducted an interview with Office Manager Christina Nova, who stated she is present when Residents withdraw funds as a witness to transactions as well as a Social Worker at times. Administrator Fuentes stated Resident statements are accessible. LPA Johnson and LPM Alvarez conducted a review if R1’s Physician Report (dated 2/10/2021) indicating R1 is able to manage own cash resources.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail Johnson	TELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20220504104523

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: 05/19/2022

NARRATIVE

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Two (2) out of seven (7) Residents interviewed, stated that they have Trust Fund accounts. Two (2) of the (2) two Residents with Trust Fund accounts, reported not having any concerns regarding their own Trust Fund Account or knowing of Residents that have Trust Fund account management concerns. Four (4) out of seven (7) Residents interviewed stated they do not have Trust Fund accounts and do not have knowledge of Residents with concerns regarding Trust Fund account management. Staff (S1) and (S3) stated they have not received reports from Residents regarding Trust Funds account management concerns.

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 allegation is 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: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3