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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 05/01/2024
Date Signed: 05/01/2024 03:53:39 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, 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
04/19/2024 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240419131644
FACILITY NAME:GARDENA RETIREMENT CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:SUSANA FUENTESFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: 89DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Office Manager Christina NovoaTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff refused to provide resident with medications.
INVESTIGATION FINDINGS:
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On 05/01/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint visit at the above mentioned facility. LPA met with Office Manager Christina Novoa and explained the purpose of the visit is to interview (3) caregivers and deliver findings. LPA also met with Administrator Susie Fuentes. On 04/29/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Administrator Susie Fuentes and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed (03/30/2024) Register of Residents, (04/23/2024) Personnel Report, Centrally Stored Medication & Destruction Record File, Destruction File Binder, (9) Resident Records, (9) Staff Trainings Records, In-Service Trainings binder, Medication Transfer Sheet/Release of Responsibility template, reviewed (9) residents' medication, and interviewed 9 residents and 6 staff members which includes the Administrator, Business Office Manager, (2) MedTechs, and (2) Caregivers.

Continue to LIC809-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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 6
Control Number 11-AS-20240419131644
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: 05/01/2024
NARRATIVE
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Allegation(s):
Staff refused to provide resident with medications.

The investigation revealed the following: Regarding the allegation "Staff refused to provide resident with medications,” it is being alleged that upon R1’s departure, R1 requested for R1’s medications and the staff refused to provide blood pressure medication. LPA observed packs of R1’s blood pressure medication in the med room. Record review of the 10/12/23 physician’s report revealed that R1 is able to manage R1’s own medication. Centrally Stored Medication and Destruction Record reveals that blood pressure medication is to be taken daily. Regarding the allegation “Staff refused to provide resident with medications," based on observation and record reviews, the preponderance of evidence has been met therefore the allegation is Substantiated.

Deficiencies were issued for this allegation.

An exit interview was conducted and plans of correction developed with the Administrator Susie Fuentes. A copy of this report and appeals rights was reviewed and left with Office Manager Christina Novoa.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20240419131644
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
CCR
87468.1(a)(16)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services.

This requirement was not met: Based on LPA observeation and record review,
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The Administrator will make arrangements to release medication to R1 by the POC due date. See details on LIC811. Proof of correction will be emailed to regina.cloyd@dss.ca.gov
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the facility did not release R1's medication upon request at discharge which poses a potential health risk to resident in care. LPA observed R1's medication in med room, blood pressure meds are to be taken daily, and R1's physcians report says R1 is able to manage R1's own medication.
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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: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
04/19/2024 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20240419131644

FACILITY NAME:GARDENA RETIREMENT CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:SUSANA FUENTESFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: 89DATE:
05/01/2024
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Office Manager Christina NovoaTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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2
3
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9
Staff does not treat resident with dignity and respect.
INVESTIGATION FINDINGS:
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On 05/01/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint visit at the above mentioned facility. LPA met with Office Manager Christina Novoa and explained the purpose of the visit is to interview (3) caregivers and deliver findings. On 04/29/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Administrator Susie Fuentes and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed (03/30/2024) Register of Residents, (04/23/2024) Personnel Report, Centrally Stored Medication & Destruction Record File, Destruction File Binder, (9) Resident Records, (9) Staff Trainings Records, In-Service Trainings binder, Medication Transfer Sheet/Release of Responsibility template, reviewed (9) residents' medication, and interviewed 9 residents and 6 staff members which includes the Administrator, Business Office Manager, (2) MedTechs, and (2) Caregivers.

Continue to LIC809-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20240419131644
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: 05/01/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation "Staff does not treat resident with dignity and respect,” it is being alleged that R1 was not treated with respect and dignity by staff and staff are very disrespectful to residents in general. Interviews conducted indicate the following: 5 out of 9 staff members are knowledgeable with residents’ rights, 7 out of 9 staff are knowledgeable about elderly abuse(s), and 9 out of 9 staff members have not witnessed staff speak disrespectfully to residents. Resident interviews revealed: 8 out of 9 residents indicated that staff speak to them respectfully and 7 out 9 residents have not witnessed staff speak disrespectful to other residents. Record review revealed that staff received in-service training on residents’ rights on 04/20/2023. Based on the interviews and record review, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

No deficiencies cited for this allegation.

An exit interview was conducted and a copy of this report was reviewed and left with Office Manager Christina Novoa.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6