197607366-3-30-2023-11-AS-MVAO-CQJUP3-20230403154453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 03/30/2023
Date Signed: 03/30/2023 12:25:30 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
05/19/2022 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220519161012

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: 82	DATE:	03/30/2023
		UNANNOUNCED	TIME BEGAN:	10:43 AM
MET WITH:	Christina Nova Office Manager		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Facility not providing a safe environment for resident.

INVESTIGATION FINDINGS:

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The purpose of this report is to clarify the allegation findings narrative documented in the report created on 10/6/2022. The “Substantiated finding remain unchanged; however, this report created on 3/30/2023 supersedes the complaint investigation report created on 10/6/2022. On 3/30/32 LPA met with Christina Nova-Office Manager.
On 10/6/22, Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced subsequent complaint investigation at the facility listed above. LPA Conducted risk assessment before entering the building. LPA was greeted by Office Manager/ Christina Novoa and later by the Administrator/ Susan Fuentes. LPA explained the purposed of the visit is to deliver findings.
The investigation consisted of the following:

On 5/23/2022, LPA Brown toured the facility and obtained Staff and Residents roster. LPA interviewed (8) residents (R1-R8) and the administrator. On 10/6/22, LPA conducted interviews with Administrator and (4) staff (S1-S4). LPA reviewed and obtained copies of residents R1’s admission agreement, physicians’ reports, appraisal and needs/services and activity calendars.
LIC 9099-C is on the next page

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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-20220519161012

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: 03/30/2023

NARRATIVE

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The investigation revealed the following:

Facility not providing a safe environment for resident.

The complainant alleges that a resident repeatedly was walking from one end to the driveway back and forth, while the delivery truck was backing into the driveway and resident might get harm. On 5/23/22, during the interview 4 out of 8 residents, stated they saw (R1) pacing back and forth in the driveway. Interview conducted with Resident (R1) indicated they like to walk/exercise in the driveway. During interview with the Administrator Fuentes, stated the day of the incident with R1 was leaving the facility and waiting for a ride. On 10/6/22, LPA interviewed staff members (1-4) All staff stated the facility is providing a safe environment. Staff members also stated residents are observed by video camera. Some of the residents like to walk around the building. Another resident would like to walk back and forth on the driveway and smoke cigarettes. LPA observed the driveway and cars are leaving in and out to park frequently. LPA reviewed R1’s physicians report and resident is not able to leave facility unassisted. LPA found enough evidence to support that above mentioned allegation.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was provided and a copy of the report was given to Christina Nova.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220519161012

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: 03/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/14/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator will submit a plan on how she will ensure that residents that are not able to leave on their own are not walking back and forth in the driveway. Administrator will submit to LPA Brown by POC due date 10/14/22.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, showed that Resident (R1) physicians report physicians assessment indicates that R1 was not able to leave the premises unassisted. This is a potential health and safety 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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC9099 (FAS) - (06/04)

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