197607366-8-11-2023-11-AS-JHAD-CV7QSZ-20230830122622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 06/16/2023
Date Signed: 08/11/2023 10:53:14 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
06/09/2023 and conducted by Evaluator Jeremiah Randle

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230609090233

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:	06/16/2023
		UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Administrator Susana Fuentes.		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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On 06/16/2023 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.

The investigation consisted of the following:

LPA conducted observation of physical plant, Staff Interviews (S1), and review of 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, Client Roster, Staff Roster) R1's Needs and Services, Functional Capability Assessment.There were no Eviction Notices in R1's file.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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-20230609090233

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 06/16/2023

NARRATIVE

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Investigation Revealed the following.

Regarding Allegation: Unlawful Eviction.
It was alleged by R1 resident's Facility Unlawfully Evicted R1. LPA Jeremiah Randle conducted an interview with (R1), R1 stated had been evicted from Gardena Retirement Center via telephone. R1 stated to LPA during telephone interview that R1 is currently in nursing home since 12/30/2022 to current. R1 stated he was on the Waiver Program. R1 stated R1 has been in a nursing home since 12/30/2022 to current, but R1 continues to pay his share of his rent. R1 stated in March 2023, R1 lost his Waiver, 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 Randle, R1 was in the hospital receiving care. S1 stated " I never told the resident R1, R1 was evicted". LPA requested to view R1’s room LPA observed R1’s name plate on the door, R1’s personal affects situated in the room, as well as R1’s mail on the dresser. R1 was not present in room as observed by LPA Randle. S1 provided LPA with a copy of the resident roster and R1’s name was still listed as a resident.

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 Administrator Susana Fuentes

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC9099 (FAS) - (06/04)

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