<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 10/06/2022
Date Signed: 10/07/2022 11:54:10 AM

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 CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:SUSANA FUENTESFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: 77DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Susana FuentesTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not providing a safe environment for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/6/22 2022 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 met was arrived was greeted by Office Manager Christina Novoa and later by administrator. LPA explained the purposed of the visit is to deliver findings on the allegation listed.

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 5 staff(S1-S5). LPA reviewed and obtained copies of residents R2 and R9 admission agreement, physicians’ reports, appraisal and needs and activity calendars.

The investigation revealed the following.:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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-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: 10/06/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The complainant alleges that a resident was walking with a walker repeatedly from one end to the driveway and back. Complainant in stated there was a truck backing in the driveway and feared the resident may get hurt. On 5/23/22, LPA interviewed Residents (R1-R8), and out of those that interview 4 stated they had saw residents pacing in the driveway and another on the side of the building and the 5th stated that they like to exercise and had walk in the driveway. LPA conducted interview with the administrator, she stated the day of the incident that particular resident was waiting for a family member and another resident like to smoke and would pace the driveway. On 10/6/22, interviewed staff members (1-5) All staff members stated the facility is a safe environment and the residents that smoke will exit the backdoor but will have to walk the driveway to enter the front of the building. Staff also mentioned residents safety are seen on video camera while outside. 2 out of 5 staff stated one residents likes to walk around the building and another resident would like to walk back and forth on the driveway and smoke cigarettes. LPA reviewed files pertaining to the allegation and both residents that were mentioned has health condition indicated they have confusion and disoriented. Based on interviews and records the above allegation is substantiated.

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.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 10/06/2022
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 residents were not able to leave the premises on their own were walk up and down the driveway.


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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3