197607366-12-17-2025-11-AS-SCIS-DQZ6GP-20260204194813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 12/17/2025
Date Signed: 12/17/2025 04:12:17 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
11/19/2025 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20251119084839

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: 82	DATE:	12/17/2025
		UNANNOUNCED	TIME BEGAN:	12:06 PM
MET WITH:	Susie Fuentes, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not ensure that resident's shower equipment was in good repair resulting in a fall.

INVESTIGATION FINDINGS:

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On 12/17/25, 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 allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 11/19/25 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Admission Record, Special Incident Report, Preplacement Appraisal Information, Medical Assessment for Residential Care Facilities for the Elderly, Appraisal/Needs and Services Plan, Enriched Residential Care Service Need and Tier Assessment, Incontinent Schedule All Shifts, Shower List, medical reports from Gardena Memorial Hospital and a Picture. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-8 (S1 – S8), and Resident -1 – Resident -8 (R1-R8).

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025

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-20251119084839

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: 12/17/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not ensure that resident's shower equipment was in good repair resulting in a fall.

It is being reported that shower equipment was not in good repair, resulting in residents fall. On 12/17/25, LPA Felisa Shirley reviewed the Special Incident Report dated 11/13/25, which reported that R1 slipped out of the shower chair during her scheduled shower, and returned back to the facility on the same day. On 12/17/25, LPA Shirley reviewed the Preplacement Appraisal Information dated 10/22/25, which documents that R1 needs help with bathing. A review of medical report from Gardena Hospital, LP dated 11/12/25 did not indicate a fracture nor a displacement. LPA Shirleys facility tour and inspection on 11/19/25 included an evaluation of the designated shower chair; no deficiencies were identified. During staff interviews, S2 indicated they were able to catch the resident and gently guide R1 into a seated position, preventing a fall. The staff member stated that there were no visible injuries and resident did not hit their head or lose consciousness as a result of the incident.

LPA Shirley interviewed staff 1 – staff 8 (S-1 – S-8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 8 (R-1 – R-8). Of those who interviewed 7 out of 8 denied the allegation, and 1 confirmed the allegation.

Based on information gathered, LPA Shirley did not find sufficient evidence to support the allegation “Staff did not ensure that resident's shower equipment was in good repair resulting in a fall,” 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: 12/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025

LIC9099 (FAS) - (06/04)

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