197607366-2-26-2024-11-AS-SCIS-D5XW3R-20240605165622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 08/14/2023
Date Signed: 02/26/2024 02:37:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20230728100550

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:	DATE:	08/14/2023
		UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Susie Fuentes, Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff stole residents Identification Card
Staff interferes with the residents' visitation
Staff threatened residents in care

INVESTIGATION FINDINGS:

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*This is an amended document to clarify findings but does not change the outcome.
On 08/14/23, Licensing Program Analyst (LPA) Felisa Shirley conducted a subsequent visit to the facility listed above for a 10-day complaint investigation. LPA arrived at facility and was met by Jasmine Navarro, Receptionist, and explained the purpose of the visit was to investigate the allegations listed above and was granted access to the facility.

The investigation consisted of the following:
On 8/4/23 LPA conducted interviews with the Administrator, Susana Fuentes, (S1)and staff 2- Staff 8 (S2-S8) and resident 1 - resident 8 (R1 – R8 LPA requested and obtained copies of the following documents: Resident & Staff roster, facility visitor sign-in sheet, Conservator Document, Community Rules, Copy of “Family Visits”, section from Admission Agreement, ID/Emergency information, physicians report, appraisals/Needs and Services Plan and any incident reports regarding ID theft.

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: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

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-20230728100550

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 08/14/2023

NARRATIVE

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Regarding allegation #1: Staff stole residents Identification Card.
It was reported that the resident’s Identification Card was stolen by the staff. During file review, LPA did not observe copies of an Identification card upon admission. LPA observed that Personal Property and Valuables page is blank. There are no incident reports reporting stolen ID’s. Staff S2 stated that R1 arrived with nothing besides the clothes they were wearing. LPA interviewed staff 1 through Staff 8, (S1-S8). LPA ask, “Has any resident report their ID being stolen.” Of those interviewed, 5 out of 8 stated No. LPA interviewed resident 1 through resident 8, (R1-R8) LPA ask, “Have you ever reported a stolen ID.” Of those interviewed, 7 out of 8 answered no their Identification card was never stolen. Resident 4 (R4) is no longer at this facility.

Based on interviews there is insufficient evidence to support the allegation: Staff stole residents Identification Card. 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.

Allegation #2: Staff interferes with residents visitation.

It was reported that the staff interferes with the residents visitation. LPA interviewed staff S1-S8, and 8 out of 8 denied the allegation. All Staff stated that there have been no refusals of visitation. Per Section XV. Family Visits, in the facility’s Admission Agreement, it states that Management encourages family and friends to visit you, subject to the Community Rules and Regulations. Per S1 and S2, a reason to reject a visit would be based on a Court order or Threat to Staff or Resident safety. LPA interviewed R1 – R8. R4 was not available. LPA ask, has any of your visitors been refused entry. Of those interviewed, 4 out of 7 answered no.

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: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230728100550

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 08/14/2023

NARRATIVE

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Based on interviews there is insufficient evidence to support the allegation: Staff interferes with visitation. 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

Allegation #3: Staff threatened residents in care

It is alleged that staff threatened to take away resident’s personal phone so that the resident can’t communicate with family. Per S1 the resident always become rattled and agitated and tries to AWOL from the facility after R1 speaks with family. For the safety and well-being of the resident S1 gave the phone back to conservator. On 8/17/23 LPA spoke with the Conservator and she felt that it is better that R1 not have the cellphone at this time. Conservator stated that RP is free to call facility to speak with R1 any time. LPA interviewed all staff, staff 1 – staff 8 (S-1 – S-8). LPA asked is there any knowledge of threats to a resident or staff. Of those interviewed 8 out of 8 stated no. LPA interviewed residents 1 – resident 8 (R-1 – R-8). LPA asked residents, has anyone threatened you? Of those interviewed, 6 out of 8 answered, No. R4 was not available.

Based on information gathered, the department did not find sufficient evidence to support allegations "Staff threatened residents in care.” 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.

No deficiencies were cited during the visit.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC9099 (FAS) - (06/04)

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