197607366-3-27-2023-11-AS-MVAO-CQCRHD-20230328130209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 11/09/2022
Date Signed: 03/27/2023 06:53:32 PM

Unsubstantiated

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
10/20/2022 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20221020162056

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: 74	DATE:	11/09/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Susana Fuentes		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are retaining a resident that requires a higher level of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, November 09, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Administrator Susana Fuentes. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: LPA Bunker interviewed staff 1-3 (S1-S3) and residents 1-7 (R1-R7). S1-S3 stated staff is not retaining a resident that requires a higher level of care. The resident was placed at the facility by her doctor. R1 is on hospice and her nurse and doctor visit her at the facility once a week. The administrator stated the hospital could not provide one on one. The facility staff is providing R1 with the necessary care and supervision according to her doctor's order.

See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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-20221020162056

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: 11/09/2022

NARRATIVE

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Continued LIC9099-C page 2

Allegation: Staff are retaining a resident that requires a higher level of care
Staff 1-3 (S1-S3) stated residents are provided with a comfortable environment. Residents 1-7 (R1-R7) state staff is providing residents with a comfortable environment. R1-R7 stated that they do not have any issues, problems, or concerns regarding the care and supervision being provided to them by the staff. S1-S3 stated the facility staff does not retain a resident that requires a higher level of care.

Investigation revealed the following: Interviews were conducted with staff 1-3 (S1-S3), and residents 1-7 (R1-R7), stated residents are provided residents with a safe, healthful, and comfortable environment. S1-S3 stated staff is trained and competent to do their jobs. S1-S3 stated R1 doctor placed R1 at this facility. R1 is on hospice. R1's doctor and nurse come to the facility once a week or as often as needed to assist R1. S1-S3 stated R1 has a history of falls and is a fall risk before she came to Gardena Retirement Center and it is documented. S1-S3 stated R1 had one fall since she was admitted. R1 slipped off her wheelchair, and the facility staff could not have prevented R1 from falling. S1-S3 stated the facility reported a special incident report to Community Care Licensing and all the appropriate agencies in a timely manner regarding the fall prior to the complaint allegation. S1-S3 stated none of the residents living here requires a higher level of care. S1-S3 stated residents in placement are compatible. R1-R7 states they are happy at the facility, and the staff is providing the necessary care and supervision needed to meet resident care needs. S1-S3 stated the allegation is false. S1-S3 and R1-R7 all denied the allegation.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099, LIC9099-C, and Confidential Names LIC811 was provided to the facility Administrator Susan Fuentes.

There were no deficiencies cited.
An exit interview was conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC9099 (FAS) - (06/04)

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