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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 12/13/2022
Date Signed: 12/13/2022 12:14:49 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
12/08/2022 and conducted by Evaluator Jeremiah Randle
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221208122033
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:
12/13/2022
UNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Administrator Susana FuentesTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unlawful Eviction.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/13/2022 at 10:00 a.m. Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to deliver the findings of the complaint with the above allegation Unlawful Eviction. LPA identified himself and discussed the purpose of the visit and the elements of the allegation with Administrator Susana Fuentes/designee Office Manager Christina Novoa .

The investigation consisted of the following:

LPA conducted observation of physical plant, Staff Interviews (S1), and R1’s Facility File, LPA requested and obtained copies of Pertinent documents pertaining to the allegation. LPA requested from the facility (Admissions Agreement, House Rules, Physicians Report /Medical Records, Client Roster, Staff Roster) Needs and Services, Functional Capability Assessment, SIR’s/SOC 341, staff / nursing notes. There were no Eviction Notices in the file.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
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 2
Control Number 11-AS-20221208122033
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: 12/13/2022
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
Investigation Revealed the following.

Regarding Allegation: Unlawful Eviction.
It was alleged by CW1 resident's Facility Unlawfully Evicted R1. CW1 stated to LPA that it was difficult to reach the facility administrator after R1's hospitalization. LPA Jeremiah Randle conducted an interview with facility administrator Susana Fuentes (S1). Susana Fuentes denied that R1 had been evicted and stated, “the resident has not been evicted or served any eviction notices”, S1 confirmed to LPA R1 was in the hospital however R1 was returned to the facility via hospital transportation. S1 stated " I never told anyone from the hospital the resident could not return to the facility". S1 requested LPA to view R1’s room LPA observed R1’s name plate on the door, R1’s personal affects situated in the room, and R1 was present in room as observed by LPA Randle.

Findings

Based on LPA’s observations and interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED.

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 UNSUBSTANTIATED.

Exit interview was conducted with the and a copy of this report was provided to Christina Novoa.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah RandleTELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2