197607366-5-24-2022-11-AS-EMAZ-CHW2N4-20220902173207

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 05/23/2022
Date Signed: 05/24/2022 08:52:54 AM

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
05/16/2022 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20220516090018

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: 67	DATE:	05/23/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Susana Fuentes		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility allowing residents to work at facility.

INVESTIGATION FINDINGS:

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On 5/23/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint visit at this facility. LPA spoke with Administrator Susie Fuentes via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to investigate the allegation listed above.

The investigation consisted of the following: On 5/23/2022 LPA conducted a tour of facility grounds and reviewed records for staff and residents. LPA conducted interviews with staff (S1-S7), and residents (R1-R6). LPA Cifuentes requested and received the following documents: Client roster, staff roster and other documentation relevant to the investigation.

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: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

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-20220516090018

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: 05/23/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Facility allowing residents to work at facility.

The complainant alleges that some residents are assisting staff with their duties and they are not fingerprint cleared. LPA reviewed facility files and spoke with administrator. Per administrator Susie Fuentes, none of the residents at the facility have been asked to complete staff jobs nor are they being paid by the facility, but two residents do shadow staff in their tasks or assist with simple things like folding linens in the laundry room. The residents see it as an activity. LPA Cifuentes interviewed residents (R1-R6) and of those interviewed, 6 out of 6 stated they had seen residents completing some tasks around the facility or following a staff member as they completed their duties, but where unaware if they were paid to do so. One resident added that they had assisted staff with activities in the past. LPA interviewed staff (S1-S7) regarding the allegation. Of those interviewed 4 out 7 stated they had seen a resident shadowing staff or assisting with simple tasks. Those who answered stated that is was not a paid position, but more of an activity for the residents.

Based on information gathered, the department did not find sufficient evidence to support allegations " Facility allowing residents to work at facility.” 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 and a copy of the LIC 9099 was provided to Administrator Susie Fuentes.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022

LIC9099 (FAS) - (06/04)

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