197607366-8-26-2024-11-AS-SCIS-DBM2L9-20241203162910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 06/05/2024
Date Signed: 08/26/2024 01:49:04 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: 92	DATE:	06/05/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Susie Fuentes, Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff not allowing visitation.
Resident has unexplained bruises.

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 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: 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, and incident reports.

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: 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)

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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: 06/05/2024

NARRATIVE

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Allegation: Staff is not allowing visitation

It was reported that staff interferes with the resident’s visitation. Per Section XV Family Visits, in the facility’s Admission Agreement, it states that Management encourages family and friends to visit, subject to the Community Rules and Regulations. During Interviews with S1, LPA learned that visitors are not allowed in the resident’s rooms if resident has an assigned roommate. It is being reported that planned visitors are being turned away. During interview with S1, LPA Shirley learned that specific visitors can visit at the front door or on the facility’s patio. Per S2, visits are scheduled for family members but sometimes they do not show up. On prior visits to this facility, it's been LPA's experience that R1 does not like to be bothered or want to talk when they are in their room. LPA interviewed staff S1-S9, LPA ask, does this facility have anyone that is not allowed to visit. Of those interviewed, 7 out of 9 answered no. LPA interviewed residents R1 – R9, LPA Does this facility allow your visitors to visit. 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 allegation is Unsubstantiated.

Con'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: 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)

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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: 06/05/2024

NARRATIVE

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Allegation: Resident has unexplained bruises

During a visit a bruise was observed on R1's wrist. On 4/11/24, LPA observed a big bluish black bruise on R-1’s left wrist. LPA ask staff what happened to R1. Staff had no idea that R1 had a bruise. LPA instructed staff to fill out and submit an incident report. LPA Shirley spoke with the Director and ask about the bruise, as it should’ve been observed and reported by staff. The Director provided progress notes stating that R-1 sometimes refuses assistance with getting dressed and showers. On 5/23/24, LPA spoke to R1 and observed that their wrist was completely healed. LPA Shirley interviewed staff -1 – Staff - 9 (S1-S9). LPA ask, does staff report bruises upon observation, and of those interviewed, 9 out of 9 answered yes. LPA Shirley interviewed residents -1- resident- 9 (R1-R9). LPA ask, have you had any bruises that you didn’t know how it happened. Out of those interviewed, 8 out of 9 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 allegation is Unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099 was provided to 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)

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