197607366-11-27-2023-11-AS-MVAO-CXZUCF-20231128142752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 02/24/2023
Date Signed: 11/27/2023 01:59:00 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
02/17/2023 and conducted by Evaluator Wendy Gibbs

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230217105407

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: 78	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Susana Fuentes		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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On 11/27/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit, to the facility listed above, to amend past complaint report from 02/24/23. LPA met with Administrator (A1), Susana Fuentes, and explained the purpose of today’s visit.
On 02/24/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced 10-day complaint visit to Gardena Retirement Center. LPA met with Administrator, Susana Fuentes, and explained the purpose of this visit, regarding the complaint allegation listed above. According to Administrator there are currently 78 residents residing in the facility.
LPA is conducting a complaint visit regarding an unlawful eviction of R1. LPA and Administrator toured the facility. LPA observed all walkways to be clean, clear, and free of obstructions or hazards. There are no bodies of water present on the premises. A comfortable temperature was maintained throughout the facility. LPA observed Resident’s morning exercise and activities.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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-20230217105407

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: 02/24/2023

NARRATIVE

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LPA requested documents pertaining to the investigation. The following documents were received and reviewed: Admission Agreement, Physicians Report, Needs & services Assessment, and nurse and physician’s notes pertaining to R1.

The investigation revealed the following:
Allegation: Unlawful Eviction
The allegation alleges the Administrator (A1) refused to accept R1 back into the facility.
During the tour LPA and Administrator inspected R1’s room. LPA observed R1’s belongings are in their room, and R1’s name is still on the placard outside the door. During the interview with Administrator (A1), stated R1 was not issued an eviction notice. A1 stated that at this time the facility is unable to provide proper care and services for R1. Administrator informed LPA, that R1 can return to facility when medically cleared. Upon file review, LPA reviewed medical documents from R1’s physician stating a higher level of care is recommended, due to the need of daily wound care and R1 needing a wound vac. The facility is unable to meet the care needs for R1.

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

No deficiencies were observed or cited.

An exit interview was conducted Administrator, Susana Fuentes and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

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