197607366-2-14-2025-11-AS-SCIS-DEY393-20250320180229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 02/14/2025
Date Signed: 02/14/2025 10:20:54 AM

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 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: 87	DATE:	02/14/2025
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Susie Fuentes, Administrator		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Resident sustained multiple unexplained bruises

INVESTIGATION FINDINGS:

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On 2/14/25, Licensing Program Analyst (LPA) Felisa Shirley, conducted a subsequent 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 -staff 5(S1 - S5) and resident 1 - resident 8 (R1 - R8).

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

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-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: 02/14/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Resident sustained multiple unexplained bruises

On 1/28/25, the department reviewed facility records. Per incident report sent to the facility on 12/24/2024, on 12/23/2024 staff 6 (S6) found bruising on right and left arm of resident 1(R1). Incident reported also noted that R1 was taken out of the facility on 12/18/2024 and 12/21/2024 and that no bruises were noted at the time of departure. R1 denied any injuries or trauma when asked by facility staff. On 1/29/2025 the department requested a list of R1’s medications. R1’s current medications include Brimonidine Tartrate Ophthalmic Solution, which has a side effect of bruising and unusual bleeding.

On 1/29/2025 the department interviewed to Administrator Susie Fuentes, who stated that she observed a family member hurrying R1 along as they walked out the door. Per administrator, R1 walks slowly, so family member was pulling her out of the door by her wrists. On 2/13/2025 the department spoke with witness 1 (W1) who stated R1 told them someone at the facility was yanking on them and squeezing on their wrist. On 1/29/25, the department interviewed R1. During the interview, LPA Shirley noted bruises on both of R1’s arms, which appeared to be healing. During interview on 1/29/2025 R1 stated that she did not know who caused the bruises on her wrists. On 1/29/2025 the department interviewed Staff 1 - Staff 5, (S1-S5). LPA asked staff if any of the residents had bruises on their arms. Of those interviewed, 2 out of 5 stated yes, and 3 answered no. on 1/29/2025 the department interviewed resident 1 - resident 8 (R1-R8). The department asked residents if they had any bruises. Of those interviewed, 6 out of 8 answered no, and 2 did not answer the question. 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 the Administrator, Susie Fuentes.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

LIC9099 (FAS) - (06/04)

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