197607366-8-19-2024-11-AS-JHAD-DB32UH-20241115164223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 06/05/2024
Date Signed: 08/19/2024 10:14:29 AM

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
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: 92	DATE:	06/05/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Susie Fuents, Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not treat resident with dignity

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/5/24.

On 6/5/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the Director, Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following: 5/23/24 LPA toured the facility and reviewed both Staff and Residents roster and files. LPA requested and received copies of ID and Emergency Information, Physician’s Reports, Enriched Residential Care Service Need and Tier Assessment, Resident Appraisals, Dietary Instructions to Kitchen, Appraisal/Needs and Services, Community Rules, Inservice training on Residents rights, and 3/23/24 Incident Report
The investigation revealed the following:
Con’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: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

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 3

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: 06/05/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Facility staff did not treat resident with dignity

It is being alleged that a resident was not treated with respect and dignity by staff and that staff were very disrespectful to them and offered no assistance in their time of need. Resident stated that staff bullied them after they requested to report an incident to the police. Staff never called the police, they only reported to facility’s administrator, (S1) who could be overheard on the phone stating that, “The cops don’t care.” It was also reported that this resident requested to be moved to another facility due to safety issues as resident stated that they were referred to as a snitch. Staff were discussing the resident’s personal business amongst each other which proved that there was no confidentiality of resident issues. Record review revealed that staff received in-service training on residents’ rights on 04/20/2023 which was prior to date of incident. LPA interviewed staff S2-S8, LPA ask, does the facility staff treat residents with dignity. Of those interviewed, 7 out of 7 answered, yes. LPA interviewed residents R1 – R8, LPA ask, does facility staff treat you with dignity. Of those interviewed, 7 out of 8 answered, yes, and 1 answered no. Based on interviews, 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 the Business Office Manager, Christina Novoa.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/05/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/19/2024 Section Cited CCR 87468.1(a)(1)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not as evidenced by	1 2 3 4 5 6 7	The Director shall retrain all staff on Resident rights and to review regulation and submit a written acknowledgement that regulation is understood and provide evidence of training to CCLD via fax or email by POC due date of 6/19/24. Proof of correction can be emailed to felisa.shirley@dss.ca.gov.
	8 9 10 11 12 13 14	Based on interview, facility staff did not treat resident with dignity and respect. This poses a potential personal rights risk to persons 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: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3