197607366-10-30-2023-11-AS-MVAO-D3BQLW-20240313121633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 10/30/2023
Date Signed: 10/30/2023 04:18:16 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
10/24/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20231024100408

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: 94	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Susie Fuentes, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Due to lack of supervision, resident got into a physical altercation with another resident

INVESTIGATION FINDINGS:

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On 10/30/23 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA spoke to Administrator Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following: On 10/30/23 LPA reviewed Resident files and interviewed both facility staff and residents. LPA reviewed and requested copies of the following records: Client Roster, Staff roster, facility files and incident report dated 10/4/23.

Continued 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: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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-20231024100408

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: 10/30/2023

NARRATIVE

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The investigation revealed the following:
Allegation: Due to lack of supervision, resident got into a physical altercation with another resident.

On 10/30/23, LPA spoke with Administrator at 10:30am she stated on 10/4/23 at 5am there was an altercation happen between two parties and the police department was called.

On 10/30/23 at 10:30 am , LPA Shirley interviewed resident 1 – resident 10 (R-1 - R-10). LPA asked, “Have you ever gotten into a physical altercation with another resident”. of those interviewed, nine out of ten residents interviewed replied in the negative. LPA asked residents had you ever had a situation/altercation and staff was not available to assist you. Of those interviewed, nine out of ten answered no, there has never been a situation/altercation that staff was not there to assist them.

On 10/30/23, at 12:00pm LPA Shirley interviewed staff 1 – staff 9 (S-1 - S-9). LPA asked if there had been any physical altercations with resident against another resident. Based on interviews 3 out of 9 staff interviewed stated that yes there was an incident that occurred on 10/4/23 with two residents that was reported to the administrator.

On 10/30/23, at 11:15am LPA reviewed facility files. During file review, LPA found that resident visited Gardena Memorial on 10/4/23 and 10/5/23 for upper extremity pain. LPA also observed unusual incident/injury report and SOC 341 dated the same date as the incident that was reported by resident.

Based on interviews and information gathered, this incident happened on 10/4/23 at around 5am, S-5 heard the commotion and intervened in the situation between the two residents and contacted Administrator. One resident elected to be taken to the hospital, the other resident chose to be patched up by ambulance but later called 911 to be transported to Gardena Memorial Hospital.

Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation: Due to lack of supervision, resident got into a physical altercation with another resident. 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 are Unsubstantiated.

Exit interview was conducted and a copy of this report was provided to the Administrator Susie Fuentes.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC9099 (FAS) - (06/04)

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