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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607366
Report Date: 07/19/2023
Date Signed: 07/19/2023 11:53:36 AM


Document Has Been Signed on 07/19/2023 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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: 81DATE:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Susana FuentesTIME COMPLETED:
11:55 AM
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On 7/19/23, LPA met with Administrator Susana Fuentes regarding 30 day Eviction Notice for R1.

11:09am LPA and Administrator Susana observed room #32, (no name plate), for resident. LPA observed that his belongings were still in his room.

LPA received the following forms from Susana Fuentes: Copy of Email dated 6/29/23 at 5:07pm re Revised Eviction notice, Copy of Email dated 6/16/23 re 30 Day Notice of Eviction, Copy of 30 Notice of Eviction, and Resident Appraisal.

A copy of this report is being signed and provided to Administrator Susana Fuentes.
SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa ShirleyTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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