197607366-2-20-2026-11-AS-SCIS-DSSQC9-20260403120240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607366
Report Date: 02/20/2026
Date Signed: 02/20/2026 04:52:01 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
07/10/2025 and conducted by Evaluator Felisa Shirley

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250710141135

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: 87	DATE:	02/20/2026
		UNANNOUNCED	TIME BEGAN:	04:38 PM
MET WITH:	Xiomara Mejia, Caregiver		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not seek medical treatment for resident in a timely manner

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026

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-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: 02/20/2026

NARRATIVE

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Allegation: Staff did not seek medical treatment for residents in a timely manner

It is being alleged that staff neglected to provide prompt medical attention to residents after an altercation. LPA Shirley reviewed Special Incident Report dated 7/10/25, which noted the following: Staff 2(S2) reported that on 7/9/25, Resident 1 (R1) and Resident 2 (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. The Department reviewed R1 and R2’s Physician Reports, dated 1/1/25. Upon review of the physicians reports for both residents involved in the altercation, LPA Shirley noted identified diagnoses that required immediate follow-up. The staff initiated medical attention but both residents declined further medical services at that time. The Department reviewed R1 and R2’s Resident Appraisals, dated 1/2025, stating that both residents are able to express and communicate their needs. The Department reviewed R1’s medical reports from St. Francis Medical Center – Emergency Room, dated 7/10/25. R1 presented to the emergency room staff with symptoms of side of neck and shoulders, separate and distinct from the incident reported on 7/9/25. Per interview, 10/1/25, S2 stated after the altercation both R1 and R2 were asked to go to the hospital, but they both declined. Per interview, 10/1/25, S2 stated that R2 called law enforcement and the police offered medical transport to the hospital for both residents, but both individuals declined.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not seek medical treatment for resident in a timely manner,” therefore, the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to Xiomara Mejia, Caregiver.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026

LIC9099 (FAS) - (06/04)

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