197607366-3-15-2023-11-AS-MVAO-CQBV96-20230327161349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 03/15/2023
Date Signed: 03/15/2023 12:45:40 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
03/09/2023 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230309161825

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: 77	DATE:	03/15/2023
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Susana Fuentes		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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On 3/15/23 at 9:36 am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-Day complaint visit to the above facility. LPA was met by Susana Fuentes, administrator, and the purpose of the visit was explained. LPA toured the physical plant prior to the investigation.

The investigation consisted of the following:

On 3/15/23 at 10:30am, LPA interviewed the administrator (S1) and attempted to interview resident (R1). LPA obtained copies of resident/staff rosters, a copy of R1s file which included (admission agreement, eviction notice, needs and service plan, physicians report, and other supporting documents).

The investigation revealed the following:

Report continued on LIC-9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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-20230309161825

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: 03/15/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Illegal Eviction

LPA interviewed administrator, (S1) about the allegation. S1 stated that S1 issued an eviction notice to R1 for nonpayment of rent. R1 was given a written 30-day eviction notice on 3/02/23, and that R1s family was notified as well. S1 stated that R1 has a history of being late on the rent, and that the family has stepped in on several occasions to get R1 out of the arrears; but that it keeps happening and the facility had no other alternative but to evict R1 on the basis of non-payment of rent.

On 3/15/23, LPA attempted to interview R1. R1 was not at the facility, at the time of the visit; nor did R1 respond to several voice mail messages left by LPA Scott calling to address the allegation and to confirm that R1 was issued an eviction notice.

Based on the interview and record review, the administrator failed to serve R1 with an eviction notice in accordance with tittle 22 regulations. A review of the eviction notice dated 03/02/23, revealed that all components of the eviction letter were included per title 22 regulations; However, a written copy of the eviction notice was not issued to Community Care Licensing within 5-days.

Therefore, the allegation of an illegal eviction is substantiated. Deficiencies cited under California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of the report was given to the administrator, Susana Fuentes.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230309161825

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: 03/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/16/2023 Section Cited CCR 87224(f)	1 2 3 4 5 6 7	A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall review title 22 regulations for evictions and dismiss the eviction notice to the resident in writing and submit a copy of the dismissal letter and acknowledgement of the regulations by the POC due date of 03/16/23.
	8 9 10 11 12 13 14	Based on the interview and record review, the licensee failed to provide a copy of the eviction notice for the resident to Community Care Licensing Department within 5 days. This poses a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC9099 (FAS) - (06/04)

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