197607366-3-25-2024-11-AS-RORN-D3YM9B-20240403092426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 03/25/2024
Date Signed: 03/25/2024 02:19:45 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
01/29/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20240129123701

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:	DATE:	03/25/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Susie Fuentes, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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On 3/25/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent complaint visit. LPA met with the Director, Susie Fuentes and explained the purpose of today's visit and was granted entry.

The investigation consisted of the following: On 2/7/24 LPA Shirley toured first floor of facility for resident interviews. LPA also requested and reviewed copies of the following records: Resident Roster, Staff roster, Physicians report, Id and Emergency Info, Preplacement Appraisal, Appraisal Needs and Services, LCD Pharmacy/Medication Info, MAR’s, Facility Agreement Form/5150 Hold, Initial Psychological Eval 4/30/21, Progress Note from PCP visit 1/16/24, Admission Agreement and SIR’s that involved resident.

Investigation revealed the following:

Con'd on 809-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: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

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-20240129123701

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: 03/25/2024

NARRATIVE

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Allegation: Illegal Eviction

The complainant alleges that this facility is illegally evicting resident – 1 (R-1.) During Visit on 2/7/24 LPA Shirley spoke with Administrator Susie Fuentes who stated R-1 was transferred to another facility because R-1 was determined to need a higher level of. R-1 was involved in several incidents which were reported to CCLD. The last incident on 1/20/24 against a staff member resulted in R-1 being transported to the hospital and treating doctor making the determination that resident needed a more controlled environment for herself and for others. LPA Shirley interviewed staff 1-8 (S1-S8), and of those interviewed, only 2 staff knew what the grounds were for an eviction. LPA Shirley spoke with residents 2-8 (R2-R8). R1 was unavailable for interview and 5 out of 8 stated that no they had never faced an eviction.

Based on information gathered, the department did not find sufficient evidence to support allegation of an "Illegal Eviction.” 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 Administrator, Susie Fuentes.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024

LIC9099 (FAS) - (06/04)

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