197607366-10-19-2021-11-AS-EMAZ-C8M25J-20211109160534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 10/19/2021
Date Signed: 10/19/2021 04:30:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20211004115959

FACILITY NAME:	GARDENA RETIREMENT CENTER		FACILITY NUMBER:	197607366
ADMINISTRATOR:	AMY PRATT		FACILITY TYPE:	740
ADDRESS:	14741 S. VERMONT AVE.		TELEPHONE:	(310) 327-4091
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	108	CENSUS: 71	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	02:47 PM
MET WITH:	Susana Fuentes		TIME COMPLETED:	04:03 PM

ALLEGATION(S):

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Resident harassing another resident at facility

INVESTIGATION FINDINGS:

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On 10/19/2021 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent investigation at the facility listed above. LPA spoke with staff Elizabeth via telephone call prior to entering the facility to conduct risk assessment questionnaire and was informed that facility had no COVID cases nor do any of the clients have symptoms. LPA arrived at facility and was greeted by staff. LPA explained the purposed of the visit was to investigate the allegations listed above and was granted access to the facility.

The investigation consisted of the following: LPA interviewed Administrator Susie Fuentes, six (6) staff (S1-S6) and six (6) residents (R1-R6). LPA inspected the facility. LPA reviewed records for residents 1-6 (R1-R6) along with the current staff/resident roster and other documents in association with the allegation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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-20211004115959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 10/19/2021

NARRATIVE

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Allegation: Resident harassing another resident at facility

The complainant alleges that R1 is being harassed by R2. On September 11, 2021 LPA Cifuentes received witness statements stating R2 was calling several residents names and making derogatory remarks towards them. On 10/4/2021 LPA Cifuentes received a faxed incident report documenting an incident of aggression between R1 and R2. LPA viewed video of incident between R1 and R2. LPA spoke with residents (R1-R6) regarding harassment and 4 out of 6 stated they had witnessed harassment between residents. LPA spoke with staff (S1-S6) regarding harassment between residents and 4 out of 6 staff stated the had witnessed harassment between residents.

Based on information gathered, the department did find sufficient evidence to support allegation " Resident harassing another resident at facility”

Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Administrator Susie Fuentes.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20211004115959

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/02/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal RIghts of Residents All Facilities 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 was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will submit a plan to LPA on how they will prevent resident on resident harassment in the future and submit it to LPA by POC due date.
	8 9 10 11 12 13 14	Based on LPA's observations and interviews facility did not insure residents in facility were free from intimidation or abuse. This poses a potential Health and Safety risk to residents 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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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