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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 07/20/2021
Date Signed: 07/20/2021 04:17:46 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
07/16/2021 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20210716163947
FACILITY NAME:GARDENA RETIREMENT CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:AMY PRATTFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: 64DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Susie FuentesTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff interfered with resident's daily living functions
Residents not accorded dignity in their relationships with staff
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced complaint investigation at above facility. LPA arrived at facility at 10:23am and was greeted by staff Carlos Aguirre. 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: On 7/20/2021 LPA Cifuentes spoke with administrator, reviewed facility records, was given a tour of facility grounds and interviewed residents 1-resident 7 as well as staff 1-staff 5. LPA also requested and received the following: staff and client rosters, admissions agreement for R1.
Regarding the allegation: Staff interfered with resident's daily living functions

The investigation revealed the following:

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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 2
Control Number 11-AS-20210716163947
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: 07/20/2021
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
On 7/20/2021 LPA Cifuentes toured facility grounds with administrator and reviewed facility files.

On 7/20/2021 LPA Cifuentes interviewed residents 1 through resident 7. Of the residents interviewed 7 out of 7 stated the facility staff was not interfering with their daily living function.

On 7/20/2021 LPA Cifuentes interviewed staff 1 through staff 5. 5 out of 5 staff stated they are not interfering with residents daily living functions.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.



Regarding the allegation: Residents not accorded dignity in their relationships with staff

The investigation revealed the following:

On 7/20/2021 LPA Cifuentes toured facility grounds with administrator and reviewed facility files.

On 7/20/2021 LPA Cifuentes interviewed residents 1 through resident 7. Of the residents interviewed 7 out of 7 stated that most of the staff treated them with politeness and dignity.

On 7/20/2021 LPA Cifuentes interviewed staff 1 through staff 5. 5 out of 5 staff stated they treat residents with dignity and respect.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.



Exit interview conducted, and a copy of the report was given to Susana Fuentes, Administrator.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2