197607366-4-18-2024-11-AS-SCIS-D5XW5A-20240605165849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:27:58 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
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:	DATE:	04/18/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Susie Fuentes, Director		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

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Facility staff did not allow resident access to make, receive private phone calls

INVESTIGATION FINDINGS:

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On 4/18/24, Licensing Program Analyst, Felisa Shirley, returned to above name facility to conclude investigation into said allegations. LPA Shirley met with Director, Susie Fuentes 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

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: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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-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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 04/18/2024

NARRATIVE

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Allegation: Facility staff did not allow resident access to make, receive private phone calls

It is being reported that resident had all forms of communication taken away. On 9/4/23 resident’s family visited the facility as they could not get through to the resident. The police were called by resident’s family in regards to missing phones and a report was filed. When police came out to investigate, the policeman gave the cell phone to resident’s family and stated it’s a crime to call the police and there’s no crime. During interviews LPA Shirley learned that resident was making prank calls to the police station and the police told the director to take the phone, and landline was unplugged as well. The police confirmed the landline phone was in the room, just not plugged in. On 9/11/23 LPA interviewed staff 1 – staff 8 (S1 – S8) asking them if any residents phone calls are being refused. Of those interviewed, 6 out of 8 answered, no. On 9/11/23 LPA Shirley interviewed residents 1 – resident 8 (R1-R8). LPA asked, do you receive calls at the front desk. Of those interviewed 3 out of 8 answered, yes.

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: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/02/2024 Section Cited CCR 85072(b)(9)	1 2 3 4 5 6 7	85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights. (9) To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies.	1 2 3 4 5 6 7	Administrator shall review the personal rights of clients and adhere to all rules and regulations for residents in care. Administrator shall return resident's personal cellphone and landline phone shall be plugged up in residents room by POC due date of 5/2/24.
	8 9 10 11 12 13 14	Based on interview and record review administrator confiscated residents personal cellphone and unplugged residents landline in residents private room of whom requires elements of care and supervision poses an immediate 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: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC9099 (FAS) - (06/04)

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