197607366-2-26-2024-11-AS-MVAO-D3BRU5-20240313131921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 02/26/2024
Date Signed: 02/26/2024 02:26:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20231121081626

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:	DATE:	02/26/2024
		UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Susie Fuentes, Administrator		TIME COMPLETED:	02:26 PM

ALLEGATION(S):

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Staff left resident unattended in a wheelchair for an extended period
Staff did not meet residents needs

INVESTIGATION FINDINGS:

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On 1/25/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Director, Susie Fuentes, 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 11/30/23 LPA reviewed resident files and toured the facility. LPA reviewed and requested copies of the following records: Resident Roster, Staff Roster, list of residents recently hospitalized, and Resident roster from 11/29/23. LPA interviewed residents only due to time constraints. On 1/18/24, LPA interviewed staff and requested and received copies of the following records: Copy of emergency services at Antelope Valley Medical Center from 11/8/23, Records from Kaiser Permanente 11/15/23, Physician's Report, and Gardena Retirement Center Community Rules.

The investigation revealed the following:
Con'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: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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-20231121081626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 02/26/2024

NARRATIVE

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Allegation: Staff left resident unattended in a wheelchair for an extended period

It is alleged that R-1 was left in their wheelchair unattended outside while they were smoking a cigarette. RP stated that they were on the phone with the resident and overheard staff telling resident to just roll their wheelchair down the ramp as the staff was now off of work. During interviews LPA found that residents are not in their wheelchairs all day. After meals residents are taken to the activities room and placed on the sofa for activities or to watch tv. Some go back to their rooms to go back to bed. They can go to the activity room upstairs if they choose to. If they are more independent then they do their own thing. LPA observes the residents in wheelchairs during every visit to the facility rolling going into the activity room after breakfast and placed on the sofa for activities. Resident was only at the facility for 3 days.

On 11/30/23 LPA interviewed residents 2 – resident 10 (R-2 – R-10). LPA asked residents, have you ever needed help from your wheelchair and did not get it? Of those interviewed, 6 out of 9 answered, no. R-1 was not available for interview. Residents generally stated that they always get help. On 1/18/24, LPA interviewed staff, staff 1 – staff 10 (S-1 – S-10). LPA asked staff, regarding wheelchair bound residents, how long are they generally in the chair? Of those interviewed 10 out of 10 stated no they are not in their wheelchairs for extended periods of time, they are taken to activities to be placed on the sofa after meals for fall risk or returned back to their rooms. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

con'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20231121081626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 02/26/2024

NARRATIVE

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Allegation: Staff did not meet residents needs

It is alleged that staff did not meet residents needs. Resident wants to be able to smoke in their room and to be able to use their electric wheelchair as resident is not able to use the manual wheelchair that was provided during the time of admission. During interviews, LPA found that resident was caught smoking in their room after the resident was told numerous times that they were not allowed to smoke in the residents rooms. Resident refused to sign the Admission Agreement and did not pay the Smokers Deposit Fee $250 that is required for all resident who wish to smoke in the permitted common areas. Electric wheelchairs were not allowed at the time the resident resided at this facility per Community rules.

LPA Shirley interviewed residents 2 – resident 10 (R2-R10). LPA ask, are all of your basic needs being met? Of those interviewed, 9 out of 9 answered yes. R-1 was not available for interview. LPA interviewed staff -1 – staff -10, (S1-S10). LPA ask, Is anyone/staff assigned to assist wheelchair residents with their daily needs. Of those interviewed, 10 out of 10 answered, yes everyone helps with their needs. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

An exit interview was conducted and a copy of the LIC 9099 was provided to Director Susie Fuentes.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC9099 (FAS) - (06/04)

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