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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 01/29/2025
Date Signed: 01/29/2025 05:09:33 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
01/27/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250127144734
FACILITY NAME:GARDENA RETIREMENT CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:SUSANA FUENTESFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: 88DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susie Fuentes, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are not permitting resident to have visitors
Staff are not permitting resident to receive phone calls
Staff are not safeguarding resident's belongings
INVESTIGATION FINDINGS:
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On 1/29/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the 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 1/29/25, LPA Shirley toured the facility and reviewed Residents file. LPA Shirley requested and reviewed copies of the following records: Staff Roster, Resident roster, Admission Record, ID and Emergency Info, Physician’s Report, Admission Agreement, Appraisal Needs and Services, Progress notes, Podiatric Evaluation & Treatment Form, Conservatorship documents, Medication Review Report, Clinical Progress Notes, Resident Personal Property and valuables, visitor log, incident reports. LPA interviewed staff 1 thru staff 5(S-1 thru S-5) and resident 1 thru resident 8 (R-1 thru R-8).

The investigation revealed the following:
Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 11-AS-20250127144734
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: 01/29/2025
NARRATIVE
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Allegation: Staff are not permitting resident to have visitors

It was reported that staff interferes with the resident’s visitation. Per Section XV Family Visits, in the facility’s Admission Agreement, it states that Management encourages family and friends to visit, subject to the Community Rules and Regulations. During Interviews with S1, LPA learned that a specific family member visit was being denied pending an investigation by the conservator. LPA Shirley requested and reviewed the visitors log and observed that R-1 receives visitors by family, friends and her conservator. R-1 has a visitor that refuses to sign the visitors log. LPA interviewed staff S1-S5, LPA ask, is staff not permitting residents from having visitors. Of those interviewed, 5 out of 5 answered, no they can have visits anytime they’d like. LPA interviewed residents R1 – R8, LPA ask, does staff allow you to have visitors. Of those interviewed, 8 out of 8 answered yes. 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 is Unsubstantiated.

Allegation: Staff are not permitting resident to receive phone calls

The details of the complaint allege that staff are not permitting residents to receive their phone calls. On 1/29/25, LPA Shirley reviewed an email to R-1’s conservator, dated 12/6/24, that the police were called to conduct a safety check as R-1 refused to come to the phone. The police came in and went to R-1’s room and the police were told by R-1 that she did not want to come to the phone because she was asleep.

LPA interviewed staff 1 through Staff 5, (S1-S5). LPA ask, does staff allow residents to have phone calls. Of those interviewed, 5 out of 5 stated yes. LPA interviewed resident 1 through resident 8, (R1-R8) LPA ask, are you allowed to receive phone calls. Of those interviewed, 8 out of 8 answered, yes. 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.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20250127144734
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: 01/29/2025
NARRATIVE
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Allegation: Staff are not safeguarding resident's belongings

It was reported that the resident’s slippers, clothing, money and driver’s license were stolen by the staff. LPA Shirley reviewed the Personal Property and Valuables form and it has one item recently listed but does not include an ID card. There are no incident reports reporting stolen ID’s. Staff S2 stated that R1 arrived with nothing besides the clothes they were wearing. LPA spoke with R-1 and she stated that she has not had a drivers license in years. Per S-1, on one occasion R-1 left this facility with a full duffle bag. S-1 tried to check the bag but R-1 did not allow her to check. When R-1 returned to the facility the duffle bag was not full. Per S-1, R-1’s money is managed by the conservator who sends money to facility and money is given to R-1. LPA reviewed R-1’s special incident reports and did not observe any reports of money being stolen. LPA interviewed staff 1 through Staff 5, (S1-S5). LPA ask, “are staff safeguarding resident’s personal belongings.” Of those interviewed, 5 out of 5 stated yes. LPA interviewed resident 1 through resident 8, (R1-R8) LPA ask, does staff make sure that you have all of your personal belongings. Of those interviewed, 6 out of 8 answered yes, and 2 answered no. 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.

There were no deficiencies cited during this visit.

LPA Shirley conducted an exit interview and a copy of this report was signed by staff Xiomara Mejia and a copy left for the Administrator, Susie Fuentes.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4