197607366-4-18-2024-11-AS-SCIS-D5XW5B-20240605165850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 09/29/2023
Date Signed: 04/18/2024 02:21:54 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
09/05/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20230905083922

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: 93	DATE:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	11:49 AM
MET WITH:	Susie Fuentes, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff dispensed medications not prescribed to resident
Facility staff did not allow resident to have private visits with family
Facility staff did not allow resident to keep their own personal possessions

INVESTIGATION FINDINGS:

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This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 9/29/23.

On 9/29/23, Licensing Program Analyst, Felisa Shirley, returned to above name facility to conclude investigation into said allegations. LPA Shirley met with Business Office Manager, Christina Novoa and explained the purpose of today's visit and was granted access.
The investigation consisted of the following:
On 9/1123 LPA requested received and reviewed the following: Staff and Resident rosters, facility visitor list, and facility files. LPA interviewed Administrator Susie Fuentes, S-1 and S-2 through - staff S-8 (S-2 - S-8). LPA interviewed resident R-1 through R-8.

The investigation revealed the following:

Cont'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: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 4

Control Number 11-AS-20230905083922

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: 09/29/2023

NARRATIVE

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Allegation: Facility staff dispensed medications not prescribed to resident
On 9/11/2023 LPA Shirley reviewed facility files. During file review, LPA reviewed resident’s medication records and actual medication and did not find any discrepancies. All required medications on the list are accounted for as given as prescribed.

On 9/11/23 LPA Shirley interviewed residents 1 – resident 8 (R1-R8). LPA asked have you ever been given the wrong medication and all eight clients interviewed stated that they have not to their knowledge. On 9/11/23 LPA Shirley interviewed staff 1 - staff 8 (S1-S8). LPA asked staff if any resident reported that they received the wrong medication and all staff interviewed stated that no resident had reported to them that they received the wrong medication.

Based on interviews and records review there is insufficient evidence to support the allegation: Facility staff dispensed medications not prescribed to resident. 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: Facility staff did not allow resident to have private visits with family
On 9/11/23 LPA reviewed facility visitors list. During review, LPA noted that between the periods of 10/11/22 and 9/11/23, resident’s daughters visited over 30 times. This number does not include the number of visits from, “family” written on visitors list. On 9/4/23, Labor Day, S1 stated that the facility had an outbreak of covid-19 and visitors were given a choice to visit or not but must wear PPE.
Cont'd

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230905083922

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: 09/29/2023

NARRATIVE

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On 9/11/23 LPA interviewed residents 1- resident 8 (R1 – R8). LPA asked residents has any of your visits been refused and all eight residents interviewed stated that their visits have not been refused. On 9/11/23 LPA Shirley interviewed staff 1 – staff 8 (S1 – S8). LPA asked staff if any one’s visits were being refused and all staff interviewed stated that no resident has had any visits denied.

Based on interviews and records review there is insufficient evidence to support the allegation: Facility staff did not allow resident to have private visits with family. 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: Facility staff did not allow resident to keep their own personal possessions

On 9/11/23 LPA interviewed the Director asking them if any personal possessions are being locked up in their office. The Director stated that the police called and said to take the residents personal phone because resident was making numerous calls to the police department. On 9/4/23, a family member called the police from the facility, police came out to investigate and gave the phone to the family member and verified that resident’s landline was in their room just unplugged. The Director gave the phone to the policeman. This facility has no knowledge regarding any missing items/possessions for this resident.

Based on interviews and records review there is insufficient evidence to support the allegation: Facility staff did not allow resident to keep their own personal possessions. 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.

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: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230905083922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 09/29/2023

NARRATIVE
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SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

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