197607366-1-11-2024-11-AS-MVAO-D5PTRE-20240528145723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:01:51 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
12/15/2023 and conducted by Evaluator Felisa Shirley

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231215151234

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: 100	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Susie Fuentes, Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not allow resident in care to leave the facility
Staff did not ensure resident in care attended his medical appointments
Residents in care are not provided adequate meals
Resident's room is in disrepair
Staff mismanaged resident's funds

INVESTIGATION FINDINGS:

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On 1/11/24, 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 12/20/23 LPA reviewed resident files and toured the facility. LPA reviewed and requested copies of the following records: Resident Roster, Staff Roster, and resident files. LPA interviewed residents only due to time constraints. On 1/11/24, LPA requested the copy of note from doctor stating that R-1 is restricted from leaving the facility.

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: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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-20231215151234

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: 01/11/2024

NARRATIVE

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Allegation: Staff do not allow resident in care to leave the facility

It is alleged that R-1 is not being allowed to leave the facility with or without assistance. On 12/20/23 LPA Shirley reviewed resident files. Based on records review, LPA observed physician’s report stating R-1 is not able to leave the facility unassisted. LPA observed ANS’s stating, unable to leave facility unassisted due to physical limitations. There is an incident report dated 3/9/23 and photo submitted to the department indicating that R-1 left the facility and was found inebriated and retrieved back to the facility. On 12/20/23 LPA interviewed residents 1 – resident 8 (R-1 – R-8). LPA asked residents, when you request to leave the facility are you allowed to leave? Of those interviewed, 6 out of 8 answered, yes. On 1/11/24, LPA interviewed staff, staff 1 – staff 7 (S-8 – S-8). LPA asked if staff, are the residents allowed to leave this facility? Of those interviewed 8 out of 8 stated yes, if there are no restrictions on file. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff did not ensure resident in care attended his medical appointments

It is alleged that staff did not ensure resident in care attended their medical appointments. During interviews LPA Shirley learned that all medical appointments for resident are in house with his treating doctor. Resident is assisted to medical office by facility staff. During file review, LPA observed the last date of medical exam by house doctor was on 12/3/23. Last date of catheter cleaning on 12/3/23. LPA Shirley interviewed residents 1 – resident 8 (R1-R8). LPA ask, when you have medical or dental appointments does facility staff arrange for transportation? Of those interviewed, 4 out of 8 answered yes and 2 out of 8 answered no they have other means of transportation. LPA interviewed staff -1 – staff -8, (S1-S8). LPA ask, what is office policy for allowing residents to go to medical and/or dental appointments. Of those interviewed, 8 out of 8 answered yes they are permitted to go to appointments if their physician’s report allows them to leave. 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: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231215151234

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: 01/11/2024

NARRATIVE

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Allegation: Residents in care are not provided adequate meals

It is alleged that residents are not provided adequate meals. Resident sometimes wants larger portions or seconds. On 1/11/24, LPA reviewed weekly menus and found the selections to be quite nutritious and well balanced. During interviews, LPA found that average sized portions are given per meal. Seconds are given to residents if food is available after the meal is served. LPA Shirley interviewed residents 1 – resident 8 (R1-R8). LPA ask, are the meals here adequate? Of those interviewed, 7 out of 8 answered yes, they are adequate. They feel the meals are fine. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Resident’s room is in disrepair

Reporting party is alleging that his room is in disrepair. R1 reports that the roof is leaking, broken cabinets and that staff has not fixed the issues. LPA toured, inspected and took pictures of the room. LPA found the roof to be repaired and painted over. Cabinets repaired. The building is old and issues are basic wear and tear. Per staff, all rooms are cleaned daily by staff. On 12/20/23 LPA interviewed residents 1 – resident 8 (R-1 – R-8). LPA asked residents, what is the condition of your room? Is your room in disrepair. Of those interviewed, 5 out of 8 answered, no. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff mismanaged resident’s funds

It is being reported that resident has not received any money from facility staff. Reporting that they receive a specific amount of money per month but has not received anything from the administrators. On 12/20/23, during file review, LPA reviewed personal funds history. All deposits are credited and several withdrawals were observed. Residents are allowed to request money from their accounts. During file review, LPA learned that this resident was irresponsible with money per a documented incident on 3/9/23. On 12/20/23 this resident requested a large amount of money that resident could not justify what money was for. LPA requested to the director and made sure resident received some cash before the Christmas holiday as resident reported that they had no cash on hand. 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: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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