197607366-12-7-2023-11-AS-SCIS-CYGNAJ-20231213091735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 09/29/2023
Date Signed: 12/07/2023 04:25:52 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
09/05/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20230905152123

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: 93	DATE:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	12:29 PM
MET WITH:	Susie Cifuentes		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff are not assisting resident

INVESTIGATION FINDINGS:

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Document is being revised but does not change the findings.
On 09/29/23, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Christina Novoa, Business Office Manager, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility.

The investigation consisted of the following:
On 9/11/23 LPA conducted interviews with the Administrator, Susana Fuentes (S1) and staff 2- Staff 8 (S2-S8) and resident 1 - resident 8 (R1 – R8.) LPA requested and obtained copies of the following documents: Staff and Resident rosters, facility visitor list, facility shower schedule, and facility files.

The investigation revealed the following:
Cont'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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-20230905152123

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: 09/29/2023

NARRATIVE

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Regarding allegation: Staff is not assisting residents.

It is being reported that staff is not assisting this resident. During file review, interviews and observations, resident is registered in the Assisted Living Waiver program and receives assistance with all ADL’s. Resident has excessive behaviors and there is currently no formal written plan in place. The current plan is redirecting residents behavior. There is no written assessment from treating doctor but family is aware of behaviors and have been in communication with staff from the facility.

LPA spoke with family and LPA interviewed staff-1 to staff-8 (S1-S8). LPA asked, when a resident needs assistance as far as necessities, or help, what is the process? Of those interviewed, 7 out of 8 answered, to tell family if supplies are needed. If family is not involved, the administrator/facility provides supplies. All staff deny not helping residents when needed. LPA interviewed resident -1 – resident -8, (R-1 – R-8). LPA asked, when you ask staff for assistance, do you get the help that you need. Of those interviewed, 5 out of 5 answered yes.

Based on interviews and file review there is insufficient evidence to support the allegation: Staff is not assisting residents. 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 allegations are Unsubstantiated.

No deficiencies were cited during the visit.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

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