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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607366
Report Date: 09/08/2023
Date Signed: 09/08/2023 01:57:28 PM


Document Has Been Signed on 09/08/2023 01:57 PM - 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: DATE:
09/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Susie Fuentes, AdministratorTIME COMPLETED:
02:00 PM
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On 9/8/23, LPA met with Administrator Susana Fuentes regarding 30 day Eviction Notice for R1.

At 12:57pm 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 30 Day Notice of Eviction dated 6/16/23, copy of 30 Day Notice of Eviction dated 7/31/23, copies of statements for balances due dated 3/31/23 and 4/30/23.

Administrator Susie will email requested copy of email sent to LPM Eva Alvarez and copy of pay history for the account of R1.


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: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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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