197607366-8-19-2024-11-AS-JHAD-DB32UJ-20241115164224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 05/23/2024
Date Signed: 08/19/2024 10:18:21 AM

Unsubstantiated

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
04/18/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20240418115622

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: 87	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Susie Fuentes, Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Lack of supervision resulted in physical altercation between residents

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 5/23/24

On 5/23/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the Business Office Manager, Christina Novoa and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following: 4/18/24 LPA toured the facility and reviewed both Staff and Residents roster and files.

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: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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-20240418115622

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: 05/23/2024

NARRATIVE

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Allegation: Lack of supervision resulted in physical altercation between residents

It is being reported that a resident kicked another resident while in care. During interviews, LPA learned both residents moved into this facility together as a couple and resided in the same room. On 3/23/24 staff observed R1 and R6 walking down the hallway and R1 was crying. S4 start walking towards the residents to find out why R1 was crying when R6 kicked R1 twice. S4 ran to intervene and divided and redirected the two residents. S4 reported the altercation to the Med Tech on duty. On 5/23/24, LPA Shirley interviewed staff 2 through staff 8(S2-S8). S1 was not available. LPA asked staff, do you believe a lack of supervision resulted in a physical altercation between residents. Of those interviewed, 7 out of 7 answered, no. LPA Shirley interviewed resident 1 – resident 8 (R1-R8). LPA ask residents, do you believe that lack of supervision results in physical altercations between residents. Of those interviewed, 6 out of 8 answered, yes, 1 answered no, and 1 had an answer other than yes or no. 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.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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