197607366-1-18-2024-11-AS-MVAO-D5PTRD-20240528145723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 01/18/2024
Date Signed: 01/18/2024 02:02:49 PM

Substantiated

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: 94	DATE:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Susie Fuentes, Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff withheld resident's personal mobility device

INVESTIGATION FINDINGS:

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On 1/18/24, 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 interviewed staff and 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

Substantiated

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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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 3

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: 01/18/2024

NARRATIVE

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Allegation: Staff withheld resident's personal mobility device

It is being reported that resident is not allowed to use their personal mobility device. On 1/18/24, LPA Shirley reviewed facility file for Gardena Retirement Center. During file review, LPA reviewed program plan for this facility. LPA observed that the Community Rules were not apart of the program plan received by Community Care Licensing Division and therefore not approved. Community Rules stated, “Motorized scooters, wheelchairs, etc are not permitted for use in the facility for safety purposes.

On 12/20/23, LPA Shirley interviewed resident 1 – resident 8 (R1-R8). LPA asked if resident has a wheelchair? Of those interviewed, 6 out of 8 did not have a wheelchair. On 1/11/24, LPA Shirley interviewed staff 1 - staff 8(S1-S8). LPA asked staff, does staff confiscate resident’s personal electrical wheelchairs? Of those interviewed, 5 out of 8 staff answered, they’re not allowed.

Based on information gathered, the department did find sufficient evidence to support allegation, Staff withheld resident's personal mobility device.

Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to the 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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/01/2024 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	80072 Personal Rights (a) each client shall have personal rights which include, but are not limited to the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not being met by:	1 2 3 4 5 6 7	Administrator will amend Community Rules and Submit to Community Care Licensing Division for approval via fax or email by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review administrator did not allow R1 to ulilize their mobility device which poses a potential Health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3