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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 02/19/2026
Date Signed: 02/19/2026 04:22:48 PM

Substantiated


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
07/10/2025 and conducted by Evaluator Felisa Shirley
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250710141135
FACILITY NAME:GARDENA RETIREMENT CENTERFACILITY NUMBER:
197607366
ADMINISTRATOR:SUSANA FUENTESFACILITY TYPE:
740
ADDRESS:14741 S. VERMONT AVE.TELEPHONE:
(310) 327-4091
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:108CENSUS: 87DATE:
02/19/2026
UNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Susie Fuentes, AdministratorTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff did not prevent resident from engaging in a physical altercation with another resident resulting in resident receiving multiple bruises
INVESTIGATION FINDINGS:
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On 2/19/2026, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. Upon arrival, LPA met with the Administrator, Susie Fuentes, and explained that the purpose of today's visit is to investigate and deliver findings for the allegations mentioned above and was granted entrance to facility grounds.

The investigation consisted of the following:

On 7/11/25 LPA Felisa Shirley requested copies of the following records: Staff and Resident rosters, Appraisals, Needs and Services Plans and Physicians Reports for Residents 1 and Resident 2, staff schedules for week of 7/6/25, incident reports for the past 6 months and current hospitalizations list. The Department conducted interviews with Staff 1 to staff 5(S1-S5), Witness 1 to Witness 5(W1-W5) and Resident 1 – Resident 5(R1 – R5).

Con’d on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
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 5
Control Number 11-AS-20250710141135
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: 02/19/2026
NARRATIVE
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The Investigation revealed the following:

Allegation: Staff did not prevent resident from engaging in a physical altercation with another resident resulting in resident receiving multiple bruises

It is being alleged that staff failed to implement necessary precautions to prevent an altercation between Resident 1 and Resident 2 (R1 and R2). LPA Shirley reviewed facility Special Incident Report dated 7/10/25, which noted the following: Staff 2 reported that on 7/9/25, R1 and R2 were arguing. R2 stated that while he was tying his shoes, R1 turned the bedroom light off. When R2 got up to turn the light back on, R1 hit him in the face with his shoe, so R2 hit him back. On 1/6/2026 LPA Shirely reviewed facility records and noted the following: physician’s reports for R1 and R2 (dated 1/1/25) indicate both have aggressive tendencies. LPA Shirley also reviewed the Appraisals and Needs and Services Plans for both residents and noted the plans do not mention anything about aggressive tendencies or plans to handle those tendencies for R1 or R2. The Department conducted interviews with facility administrator Susie Fuentes on 11/19/2025. During the interview, Fuentes stated that R1 and R2 had a history of altercations and that facility staff were aware. Furthermore, Administrator Fuentes stated staff are trained to immediately notify law enforcement regarding any suspected criminal act or physical abuse involving residents and that she felt better training should be provided for the staff. The department interviewed facility Staff 1 to staff 5(S1-S5), and of those interviewed, 2 out of 5 staff stated R1 and R2 had a previous history of aggressive speech or actions, with one of the staff adding that it had caused the residents to be moved to another room. The department also conducted interviews with facility residents, Resident 1 - Resident 5 (R1 – R5). Of those interviewed, 2 out of 5 stated R1 and R2 had a history of aggression

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250710141135
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: 02/19/2026
NARRATIVE
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towards each other. On 8/4/25, the department interviewed Witness 2 (W2), who reported that R1 spoke to them and alleged that a physical altercation had occurred at the facility involving their roommate. According to W2, R1 stated the roommate struck them in the back and further alleged that facility staff failed to intervene or take action when the incident occurred. The resident reportedly noted that this is the second or third similar occurrence involving the same roommate.


Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

A Deficiencies was cited during today's visit.

An exit interview was conducted, and plans of corrections were developed with the Administrator, Susie Fuentes. A copy of this report and appeals rights were provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20250710141135
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2026
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met, as evidenced by:
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The Administrator shall review Title 22 section 80078 (a) and provide in-service training to staff on implementing necessary precautions to prevent altercations between residents and providing more observation of the residents. Copy of training sign in sheet and written statement acknowledging understanding of Title 22 80078(a) shall be submitted to the department by the POC due date of 3/5/26 via email to felisa.shirley@dss.ca.gov or fax to 424-544-1016.

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Based on records reviewed and interviews, facility staff did not have a plan in place to handle aggressive verbal and physical altercations between residents, which resulted in a physical altercation between R1 and R2 occurring on 7/9/25. This poses a possible health, safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5