197607366-10-28-2025-11-AS-EMAZ-DNM2PZ-20251120163511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 10/28/2025
Date Signed: 10/28/2025 04:51:38 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20250729121705

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: 88	DATE:	10/28/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Susana Fuentes		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not provide proper supervision to resident in care resulting in a broken hip.

INVESTIGATION FINDINGS:

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On 10/28/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with Administrator Susana Fuentes, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During today’s visit, LPA conducted a facility inspection, interviewed Staff S1-S6, interviewed Resident’s R2-R10, and received the Staff Roster (dated 10/28/2025), Resident Roster (dated 10/27/2025), Alert Progress Notes (dated 12/26/24, 01/01/25, 01/12/25, 01/26/25, and 02/19/25), Unusual Incident/Injury Report (dated 02/13/25 and 01/02/25), and Point of Care Audit Report (dated January 2025 to February 2025)
During the initial visit on 07/30/2025, LPA Lee received the following documents Staff Roster (dated 7/30/25), Resident Roster (dated 7/28/25), R1's Resident Pre-placement Appraisal (1/30/25), R1's Incident reports (dated 2/13/25), R1's Needs and Services Plan (dated 4/9/24) R1's Physician's Report (dated 1/1/25), R1's Admission Agreement (dated 3/10/23).
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

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-20250729121705

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GARDENA RETIREMENT CENTER	FACILITY NUMBER: 197607366
	VISIT DATE: 10/28/2025

NARRATIVE

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Allegation: Staff did not provide proper supervision to resident in care resulting in a broken hip.
The allegation alleges a resident fell at the facility resulting in a broken hip and staff did not know how the resident fell.

During the facility inspection, LPA observed all walkways and hallways were observed clean, clear, and free of hazards and obstructions. All hallways had ample lighting.

During record review, LPA received and reviewed R1’s Physician’s Report, dated 01/01/2025, that indicates R1 is ambulatory and is able to independently transfer to and from bed. It is indicated R1 uses a walker for unsteady gait and requires assistance with bathing, grooming, and dressing. LPA received and reviewed R1’s Appraisal/Needs and Service Plan, dated 04/09/24, that indicates R1 requires assistance with activities of daily living (ADL), and that R1 refuses assistance and says they are able to do it themselves. LPA received and reviewed the Point of Care Audit Report that documents the time resident health and safety checks are conducted, bathing assistance is provided, and meal attendance. In the document, LPA observed health and safety checks conducted on 02/12/2025 at 11pm and 11:26pm, and on 02/13/2025 at 2:43am and 7am. Additionally, LPA observed meal attendance documented on 02/13/2025 at 8:11am.
During interviews with Staff S1-S6, they were asked if R1 was a fall risk, five (5) out of six (6) stated no, R1 was not a fall risk. Additionally, Staff S1-S6 were asked how often residents who are fall risks are checked on, six (6) out of six (6) stated as frequently as possible, every 15 to 30 minutes.
During interviews with Residents R2-R10, were asked if they feel there is enough staff to provide proper supervision, nine (9) out of nine (9) stated yes, there is enough staff to provide proper supervision. Additionally, Residents R2-R9 were asked if staff check on them when they are in their room, nine (9) out of nine (9) stated yes, staff conduct frequent checks on them when they are in their rooms.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

During today's visit, LPA did not observe or cite any deficiencies.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025

LIC9099 (FAS) - (06/04)

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