197607366-10-11-2021-11-AS-EMAZ-C8DNZ3-20211102105340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 08/05/2021
Date Signed: 10/11/2021 02:17:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20210701084959

FACILITY NAME:	GARDENA RETIREMENT CENTER		FACILITY NUMBER:	197607366
ADMINISTRATOR:	AMY PRATT		FACILITY TYPE:	740
ADDRESS:	14741 S. VERMONT AVE.		TELEPHONE:	(310) 327-4091
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	108	CENSUS:	DATE:	08/05/2021
		UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	Susie Fuentes		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility not adhering to Admissions Agreement.
Resident is not being allowed to smoke.

INVESTIGATION FINDINGS:

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This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created 8/5/2021.

On 08/5/21, Licensing Program Analyst (LPA) Stephanie CIfuentes conducted an unannounced subsequent complaint visit at this facility. LPA met with Susie Fuentes, Administrator, and explained the purpose of today's visit is to deliver findings.

The investigation consisted of the following: On 7/8/2021 LPA Cifuentes spoke with administrator, reviewed facility records, was given a tour of facility grounds and interviewed residents 1-resident 5 (R1-R5) as well as staff 1-staff 4 (S1-S4). On 7/20/2021 LPA interviewed residents 6-resident 7 (R6-R7) as well as staff 5-staff 6 (S5-S6). LPA also requested and received the following: admissions agreement for R1, staff roster and resident roster.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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-20210701084959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 08/05/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Facility not adhering to Admissions Agreement.

The complainant reports (R1)’s admissions agreement states they were paying to receive a private room and that administrator then moved someone into the room with (R1). LPA reviewed admissions agreement, which did not indicate whether (R1) was paying for a private room or a shared room. LPA found that admissions agreements do not indicate whether client has a single or double room. Per administrator, (R2) was put into the room with (R1) as there was no indication in the records that (R1) had a private room. Resident is on the ALW program(Assisted Living Waiver) and the program is paying for a shared room. Administrator informed LPA that due to Covid-19 precautions, residents had not been sharing rooms previously, which led (R1) to think they had a private room. When R1 informed Administrator they believed they had a private room, R1 and Administrator reviewed admissions agreement with ALW Social worker and (R1) was informed they had a shared room. LPA also interviewed residents (R1-R7) and found that 6 out of 7 were paying for the type of accommodation they currently have.

Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

Allegation: Resident is not being allowed to smoke.

The complainant reported (R1) is not being allowed to smoke. LPA spoke to administrator who stated all residents are allowed to smoke, they just have to do so in the facilities designated smoking area. LPA interviewed (R1-R7) about whether or not they were allowed to smoke in smoking area, all residents stated facility allows smoking in the smoking area. LPA interviewed (S1-S6) about whether or not residents were allowed to smoke, and all stated residents are allowed to smoke in designated smoking area.

Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R-1)'s service records, incident report, and interviews conducted and found no evidence to support the allegations: "Facility not adhering to admissions agreement" and "Resident not being allowed to smoke"
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Susie Fuentes and a copy of the report was provided by email.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC9099 (FAS) - (06/04)

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