197607366-11-13-2024-11-AS-SCIS-DCJW22-20250102155336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 11/13/2024
Date Signed: 11/13/2024 11:52:17 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
11/20/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20231120204358

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:	11/13/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Susie Fuentes, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident developed pressure injuries while in care.
Staff did not seek medical attention to resident.

INVESTIGATION FINDINGS:

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

On 11/13/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by facility Administrator, Susie Fuentes, and explained the purpose of the visit is to deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 11/21/2023 The department toured the facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. The department requested and received copies of the following records: Staff Roster, Resident Rosters, files of residents on hospice services, and list of residents recently hospitalized. On 11/30/2023 the department requested Harbor-UCLA medical records, facility chart, and conducted interviews with staff from this facility, facility residents, family members and staff from Harbor-UCLA, and reviewed medical records/reports. The department conducted interviews with residents 1-resident 3 (R1-R3) and staff 1-staff6(S1-S6).

The investigation revealed the following:

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: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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 5

Control Number 11-AS-20231120204358

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: 11/13/2024

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: Resident developed pressure injuries while in care.

It is alleged that due to staff neglect, Resident 1 (R1) was observed with stage 3 pressure injuries. The department reviewed facility Admissions Agreement which shows that R1 was admitted to the above-mentioned facility on 06/8/2023. During admission, the facility staff conducted a skin check and noted closed wounds on the left lower buttocks area. The Department interviewed facility Administrator, Susie Fuentes, who stated that R1 did have a pressure injury, but it was within guidelines. The department reviewed Nova Vita medical records, which show that from 7/16/23 thru 11/8/23, R1 was receiving home health for skilled nursing services and physical therapy. No orders for wound care were found in Nova Vita’s records. The department reviewed facilities Resident Rotation Log for R1 for the month of October. The log has entries from 10/8/2023 to 10/29/2023 and shows sporadic notations of dates and times R1 was rotated from 10/8/2023 to 10/14/2023. The log the skips to 10/17/2023 with one entry and then again skips to 10/29/2023 with one entry. Per records from Harbor UCLA Medical Center, on 11/11/2023, R1 was admitted to the Harbor UCLA Medical Center for the chief complaint of basic life support measures, and shortness of breath. Further review of Harbor UCLA medical records indicates that on 11/12/23 R1 was found to have two pressure injuries: Stage 2 pressure injury to sacral coccyx area, and stage 3 pressure injury to right ischium. A review of facility records indicates that on a body check conducted on 10/31/2023, facility staff noted a change in condition to R1, and under pressure injury, they noted small open sore. The accompanying diagram has markings over the lower right and left ischial tuberosity. A body check conducted by

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: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20231120204358

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: 11/13/2024

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

facility staff on 11/11/2023 when R1 was transferred to Harbor UCLA Medical Center indicated R1 had a continuous sore. Further review of facility records found no indication of pressure injuries being treated by or assessed by a doctor or another licensed medical professional. The Department interviewed facility staff 1 – Staff 6 (S1-S6), and asked if R1 had any pressures injuries, of those interviewed 5 out of 6 staff were aware of pressure injury, and 2 out of 6 admitted to treating R1’s pressure injuries with A+D topical ointment.

Based on 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 LIC9099-D.

Allegation: Staff did not seek medical attention to resident.

The department reviewed facility Admissions Agreement which shows that R1 was admitted to the facility on 06/8/2023. Nova Vita medical records show that R1 was receiving home health service from 7/16/23 thru 11/8/23, R1 was receiving home health for skilled nursing services and physical therapy. The home health records did not show any wound care orders. A review of Nova Vita’s notes shows no indications of pressure injuries. A review of facility records indicates that on a body check conducted on 10/31/2023, facility staff noted a change in condition to R1, and under pressure injury, they noted small open sore. The accompanying diagram has markings over the lower right and left ischial tuberosity. A body check conducted by facility staff on 11/11/2023

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: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20231120204358

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: 11/13/2024

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

indicated R1 had a continuous sore. The Department interviewed facility staff 1 – Staff 6 (S1-S6), and asked if R1 had any pressures injuries, of those interviewed 5 out of 6 staff were aware of pressure injury, and 2 out of 6 admitted to treating R1’s pressure injuries with A+D topical ointment at the direction of the facilities medical technicians(med-techs). The department conducted a further review of facility records and found no indication of pressure injuries being treated by or assessed by a doctor or another licensed medical professional from 10/31/2023 to 11/11/2023 when R1 was admitted Harbor UCLA Medical Center. The department reviewed Harbor UCLA medical records which indicate that R1 was admitted on 11/11/2023 and that on 11/12/23 R1 was found to have two pressure injuries: Stage 2 pressure injury to sacral coccyx area, and stage 3 pressure injury to right ischium.

Civil Penalty:
An immediate $500 Civil Penalty assessed.

Enhanced Civil Penalty:
At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was completed with Administrator Susie Fuentes, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20231120204358

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: 11/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/14/2024 Section Cited CCR 87468.2(8)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities 8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Director shall retrain all staff on incontinence and medical referrrals, 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 11/27/24. Proof of correction can be emailed to felisa.shirley@dss.ca.gov.
	8 9 10 11 12 13 14	Based on interviews and record reviews, due to facility staffs neglect in the care of R1 led to pressure injuries. This poses a potential health and safety risk to all residents in care.	8 9 10 11 12 13 14
Type A 11/14/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Director shall retrain all staff on incontinence and medical referrals 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 11/27/24. Proof of correction can be emailed to felisa.shirley@dss.ca.gov.
	8 9 10 11 12 13 14	Based on interviews and record reviews, facility staff failed to not ensure R1 received timely medical attention. This poses a potential health and safety risk to all residents in care.	8 9 10 11 12 13 14

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: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5