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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 12/19/2022
Date Signed: 12/19/2022 12:23:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
10/03/2022 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221003130042
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: 71DATE:
12/19/2022
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Susana FuentesTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident sustained an unexplained injury while in care.
Staff did not seek medical care for resident in a timely manner.
INVESTIGATION FINDINGS:
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On 12/19/2022 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Susana Fuentes. The purpose of the visit was to deliver findings on the allegations listed above.

The investigation consisted of the following: On 10/11/2022 Licensing Program Analyst (LPA) Don Senaha initiated and interviewed residents (R1-R10), Administrator and staff (S1-S6). LPA requested and obtained resident, facility and medical records.

Investigation revealed:

Allegation: Resident sustained an unexplained injury while in care. During the course of the investigation, LPA was able to find evidence supporting the allegation. Record reviews indicate the following: on 09/29/22 at 05:00am, Administrator told staff to call 911. R1 was sent to the hospital due to a bleeding wound.
Substantiated
Estimated Days of Completion: 15
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
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-20221003130042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: GARDENA RETIREMENT CENTER
FACILITY NUMBER: 197607366
VISIT DATE: 12/19/2022
NARRATIVE
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Hospital records show R1’s wound on the right lower leg was a “gaping and deep” 6cm x 3cm. Per the paramedics, care home staff did not know when or how R1 received this wound. Interviews indicate the following: Per interview with S5, on 9/28/22 at 03:20pm S5 noticed blood coming out on R1’s right leg, S5 notified S6 that R1 had a blister that had popped. S6 provided S5 a band aid for R1's wound, S6 did not assess R1’s wound. Per interview with S4, on 09/29/22 at 05:15am S4 noticed blood on R1's leg. Administrator was notified via facetime. Administrator immediately told staff to call 911. Per interview with S6, On 10/2/22 when S6 cleaned the stitches and saw it, “it was bigger than I thought”. S6 stated, “I did not check it, that was my mistake”. Administrator stated, "Staff should have reported the wound to me right away.". S5 was given counseling and was told the protocols for incidents.Based on the Department’s interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “resident sustained an unexplained injury while in care” is found to be “Substantiated” California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Allegation: Staff did not seek medical care for resident in a timely manner. During the course of the investigation, LPA was able to find evidence supporting the allegation. It is being alleged that R1’s wound was discovered by staff sometime on the night of 9/28/22 and R1 was not brought into ER until the morning on 9/29/22. Record reviews indicate the following: On 09/29/22 at 05:00am, Administrator told staff to call 911. R1 was sent to the hospital due to a bleeding wound. Hospital records show R1’s wound on the right lower leg was a “gaping and deep” 6cm x 3cm. Interviews indicate the following: Per S5, on 9/28/22 at 03:20pm S5 noticed blood coming out on R1’s right leg. S5 notified S6 that R1 had a blister that had popped. S6 provided S5 a band aid for R1s wound, S6 did not conduct assessment of R1’s wound. Per interview with S4, on 09/29/22 at 05:15am S4 noticed blood on R1's leg. S4 called S3 and S7 to witness the wound bleeding and S7 called Administrator via facetime. Administrator told staff to call 911. On 10/2/22 when S6 cleaned R1's stitches and stated, “it was bigger than I thought”. S6 stated, “I did not check it, that was my mistake”. Administrator stated, "Staff should have reported the wound to me right away.". Based on record reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “resident sustained an unexplained injury while in care” through neglect and lack of care and supervision is found to be “Substantiated” California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

A copy of this report and appeals rights were provided during the visit.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20221003130042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER
FACILITY NUMBER: 197607366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2023
Section Cited
CCR
87466
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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…
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The licensee agreed to read, understand, Title 22 Regulation 87466 Observation of the Resident regulations. Licensee to do in-service training with staff on observation of resident and send proof of the in-service with signatures of staff. Proof of correction to CCLD by POC due date of 01/03/2023.
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This requirement not met as evidenced by: Based on record reviews and interviews, resident (R1) was injured due to neglect/lack of care and supervision and suffered an injury to the leg which poses an immediate health and safety risk to persons in care.
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Type B
01/03/2023
Section Cited
CCR
87411(d)(5)
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87411 Personnel Requirements-General(d)(5) All personnel shall be given on the job training or have related experience assigned to them. This training and/or related experience…(5) Knowledge necessary in order to recognize early signs of illness and the need for professional help…
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The licensee agreed to read, understand, sign and date Title 22 Regulation 87411(d)(5) Personnel Requirements-General. Licensee to do in-service training with staff on seeking medical attention and send proof of the in-service with signatures of staff. Proof of correction to CCLD by POC due date of 01/03/2023.
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This requirement not met as evidenced by: Based on record reviews and interviews, resident (R1) was injured due to neglect/lack of care and supervision and suffered an injury to the leg which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3