197607366-4-11-2024-11-AS-SCIS-DBM2LA-20241203162910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 04/11/2024
Date Signed: 04/11/2024 04:09:42 PM

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
04/05/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20240405100037

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: 98	DATE:	04/11/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Susie Fuentes, Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff stole ID from resident
Facility is not ensuring resident goes to medical appointments
Facility is not administering medications as ordered by doctor
Facility is not allowing resident to communicate with family members

INVESTIGATION FINDINGS:

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On 4/11/24 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: On 4/11/24 LPA toured the facility and reviewed both Staff and Residents files. LPA requested and reviewed copies of the following records: Staff Roster, Resident roster, Physician’s Report, Id form, Appraisal Needs and Services, Progress notes, Conservatorship documents, MAR, expired prescriptions, monthly assessments, Podiatry appointment, Resident Personal Property and valuables, IHSS documents, visitor log, incident reports and picture of resident.

The investigation revealed the following:

Con'd 0n 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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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-20240405100037

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: 04/11/2024

NARRATIVE

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Allegation: Facility staff stole ID from resident

It was reported that the resident’s Identification Card was stolen by the staff. During file review, LPA did not observe copies of an Identification card upon admission. LPA observed that Personal Property and Valuables page has one item recently listed but does not include an ID card. There are no incident reports reporting stolen ID’s. Staff S2 stated that R1 arrived with nothing besides the clothes they were wearing. LPA interviewed staff 1 through Staff 9, (S1-S9). LPA ask, “Did staff steal ID card from resident.” Of those interviewed, 9 out of 9 stated No. LPA interviewed resident 1 through resident 9, (R1-R9) LPA ask, Has staff stolen your ID card. Of those interviewed, 8 out of 8 answered 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 allegations are Unsubstantiated.

Allegation: Facility is not ensuring resident goes to medical appointments

It is being reported that this facility is not ensuring that resident goes to all medical appointments. On 4/11/24, upon R1’s file review, LPA Shirley observed 9 monthly 30 min assessments, a copy of a podiatry appointment which was refused by R1. On 4/11/24, LPA Shirley interviewed staff 1 through staff 9(S1-S9). LPA asked staff, is facility staff ensuring that residents go to medical appointments. Of those interviewed, 8 out of 9 answered yes. LPA Shirley interviewed resident 1 – resident 9 (R1-R9). LPA ask residents, are you allowed to see the doctor or attend medical appointments, 8 out of 9 answered, yes. 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 is not administering medications as ordered by doctor

It was reported that staff is not administering medications as instructed by doctor. During file review, LPA Shirley observed copies of the MAR for R1 which records last date of medication administered was 6/7/23. S3 stated that R1 does allow appointment for in-house doctor assessments but refuses to go to the doctor to have prescription updated and filled. R1 is out of medication as of 4/11/24. LPA interviewed staff 1 through Staff 9, (S1-S9). LPA ask, is medication being administered as ordered by the doctor. Of those interviewed, 8 out of 9 stated yes. LPA interviewed resident 1 through resident 9, (R1-R9) LPA ask, are you receiving your medications as ordered by the doctor. Of those interviewed, 6 out of 9 answered, yes. 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.

Cond'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240405100037

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: 04/11/2024

NARRATIVE

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Allegation: Facility is not allowing resident to communicate with family members

It was reported that staff is not allowing phone calls from one specific family member. When LPA arrived at this facility, LPA Shirley observed R1 at the front desk talking on the phone. When R1 was done with their phone call, LPA approached R1 and advised them that I am here to investigate a complaint and if I could ask them a couple of questions regarding this complaint. R1 answered yes. LPA ask R1 who were they speaking to on the phone. R1 answered that they were talking to their family member that they speak to every morning. LPA interviewed staff 1 through Staff 9, (S1-S9). LPA ask, does staff not allow residents to communicate with family members. Of those interviewed, 6 out of 9 stated yes residents are allowed to communicate with family members. LPA interviewed resident 1 through resident 9, (R1-R9) LPA ask, are you allowed to communicate with your family members. Of those interviewed, 9 out of 9 answered, yes. 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.

Based on information gathered, the department did not find sufficient evidence to support these allegations, therefore these allegations are Unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099 was provided to 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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

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