197607366-8-27-2021-11-AS-EMAZ-C82QGG-20211022120928

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 08/25/2021
Date Signed: 08/27/2021 08:40:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20210819151014

FACILITY NAME:	GARDENA RETIREMENT CENTER		FACILITY NUMBER:	197607366
ADMINISTRATOR:	AMY PRATT		FACILITY TYPE:	740
ADDRESS:	14741 S. VERMONT AVE.		TELEPHONE:	(310) 327-4091
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	108	CENSUS: 64	DATE:	08/25/2021
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Susie Fuentes-Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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On 08/25/21, Licensing Program Analyst (LPA) Stephanie CIfuentes conducted an unannounced initial complaint visit at this facility. LPA met with Susie Fuentes, Administrator, and explained the purpose of today's visit is to investigate the allegation listed above.

The investigation consisted of the following: On 8/25/2021 LPA Cifuentes spoke with administrator, reviewed facility records, was given a tour of facility grounds and interviewed residents 1-resident 6 (R1-R6) as well as staff 1-staff 5 (S1-S5). LPA also requested and received the following: admissions agreement , staff roster and resident roster

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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-20210819151014

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 08/25/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Facility is in disrepair

The complainant alleges toilets on first floor have been out of order for three weeks and that elevator is faulty. LPA spoke with administrator, who stated that some toilets have been clogged with diapers or wipes, but that they have been immediately unclogged by facility staff or a plumber has been called. LPA inspected facility grounds and found working toilets in all 10 of the resident’s rooms checked. LPA also found the elevator to be in good repair. LPA spoke to residents (R1-R6) regarding their bathrooms. 6 out of 6 residents interviewed stated their bathroom was currently working and that there had been no issues with their toilets in the past month. LPA also asked residents about elevator and was told it was working correctly. LPA also interviewed staff (S1-S5) and 4 out of the 5 stated residents had working bathrooms and that there had been no issue with the resident’s toilets. When asked about the elevators, all 5 staff interviewed stated the elevators were working correctly.

Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of records and interviews conducted and found no evidence to support the allegation: " Facility is in disrepair ".

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Susie Fuentes and a copy of the report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC9099 (FAS) - (06/04)

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