197607366-7-9-2026-11-AS-SCIS-DWDSVS-20260727141311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 07/09/2026
Date Signed: 07/09/2026 04:43:36 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
12/08/2025 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20251208142435

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: 91	DATE:	07/09/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Susie Fuentes, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Due to staff neglect, resident fell and sustained a fractured nose and black eye

INVESTIGATION FINDINGS:

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On 7/9/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Susie Fuentes and explained the purpose of the visit is to investigate and deliver findings for the allegation mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 7/9/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Facility Fall Risk List, Unusual Incident/Injury Report, Face Sheet/Admission Record, Identification and Emergency Information, Medical Assessment for Residential Care Facilities for the Elderly, Functional Capability Assessment, Resident Appraisal, Dietary Instructions to Kitchen, Appraisal/Needs and Services Plan, Detailed Written Orders and Harbor – UCLA Medical Center Medical Report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff -1 – Staff -5 (S1 – S5), and Resident -1 – Resident -6 (R1-R6). Staff 6 (S6) was interviewed on 12/4/25 during Case Management visit.

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

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-20251208142435

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: 07/09/2026

NARRATIVE

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The investigation revealed the following:

Allegation: Due to staff neglect, resident fell and sustained a fractured nose and black eye

The department received and reviewed the Unusual Incident Report dated 12/2/25, stating R1 was being transported to her room when S6 reported she tripped, and R1 fell forward out of her wheelchair and hit her face. Upon review of medical records from Harbor – UCLA Medical Center dated 11/29/25, R1 was admitted due to a mechanical fall. On 7/9/26, the department reviewed Admission Record and noted R1 was admitted to the Gardena Retirement Center on 9/20/24 and has a history of falls. Diagnosis per Physician’s Report dated 7/29/25, HTN (hypertension), HLD (hyperlipidemia), hypothyroidism, and dementia. Per review of Resident Appraisal dated, 12/2/25, R1 was hospitalized (11/29/25 – 12/1/25) for an accidental injury – resulting in a nasal bone fracture. CT scan shows nasal bone fracture, negative head CT for acute bleed. Overall health condition included dementia, non-ambulatory, motor impairment: uses a wheelchair, special diet: Low carb, puree, need assistance with bathing and dressing. Per review of Appraisal/Needs and Services, 12/15/25, R1 has no known allergies, poor posture and poor appetite. Per interview with S1, 7/9/26, R1 did not fall in the shower, she fell while being transported to her room following being showered. S1 stated it was an accident. On 7/9/26, R1 stated she was scared as S6 was going to fast. Per interview with S5, 7/9/26, R1 leans to the side. Staff repositions R1 in the straight position, but R1 slides back down and continue to lean to the side. Per interview with S6, 12/4/25, R1 does not like to use the chair. S6 stated she almost lost her balance as she pushed R1 in the wheelchair after R1 abruptly put her feet on the floor which caused R1 to fall forward.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 3 out of 5 denied the allegation and 2 staff did not know. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation and 1 resident confirmed it.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Due to staff neglect, resident fell and sustained a fractured nose and black eye,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Susie Fuentes.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

LIC9099 (FAS) - (06/04)

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