Gardena Retirement Center

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: 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.

(a) Residents in all residential care facilities for the elderly shall have all the following personal rights: (2) to be accorded safe, heathful and comfortable accommodations...This requirement was not met as evidenceBy: Based on record review and interviews, the Licensee did not permit R1 to return back to the facility which posed a potential personal rights risk to the resident in care.

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons... Thirty (30) days written notice to the resident is required except...(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. Based on interviewed and record review the licensee did not comply with the section cited above. On 08/19/2025 the facility was informed that the R1 was ready to be discharged form the hospital A1 did not want R1 back which posed a potential health and safety risk to resident in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement was not met as evidenced by: Based on interviews and record reviews, facility staff failed to not ensure R1 received timely medical attention. This poses a potential health and safety risk to all residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement was not met as evidenced by: Based on interviews and record reviews, due to facility staffs neglect in the care of R1 led to pressure injuries. This poses a potential health and safety risk to all residents in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not as evidenced by Based on interview, facility staff did not treat resident with dignity and respect. This poses a potential personal rights risk to persons in care.

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services.This requirement was not met: Based on LPA observeation and record review, the facility did not release R1's medication upon request at discharge which poses a potential health risk to resident in care. LPA observed R1's medication in med room, blood pressure meds are to be taken daily, and R1's physcians report says R1 is able to manage R1's own medication.

85072 Personal Rights(b) The licensee shall insure that each client is accorded the following personal rights. (9) To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies. Based on interview and record review administrator confiscated residents personal cellphone and unplugged residents landline in residents private room of whom requires elements of care and supervision poses an immediate Health and safety risk to residents in care.

80072 Personal Rights(a) each client shall have personal rights which include, but are not limited to the following:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.This requirement is not being met by: Based on interview and record review administrator did not allow R1 to ulilize their mobility device which poses a potential Health and safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not being met by: This requirement is not met as evidence by:Based on interview and record review administrator made resident sit outside until sober and confining a resident to their room who require elements of care and supervision poses an immediate Health and safety risk to residents in care

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidence by: Based on interviews conducted and records reviewed, showed that Resident (R1) physicians report physicians assessment indicates that R1 was not able to leave the premises unassisted.This is a potential health and safety risk to residents in care.

A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on the interview and record review, the licensee failed to provide a copy of the eviction notice for the resident to Community Care Licensing Department within 5 days. This poses a potential personal rights risk to residents in care.

87411 Personnel Requirements-General(d)(5) All personnel shall be given on the job training or have related experience assigned to them. This training and/or related experience…(5) Knowledge necessary in order to recognize early signs of illness and the need for professional help… This requirement not met as evidenced by: Based on record reviews and interviews, resident (R1) was injured due to neglect/lack of care and supervision and suffered an injury to the leg which poses an immediate health and safety risk to persons in care.

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs… This requirement not met as evidenced by: Based on record reviews and interviews, resident (R1) was injured due to neglect/lack of care and supervision and suffered an injury to the leg which poses an immediate health and safety risk to persons in care.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidence by: Based on interviews conducted and records reviewed, showed that residents were not able to leave the premises on their own were walk up and down the driveway.This is a potential health and safety risk to residents in care.

The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes...This requirement not met as evidenced by: On 3/22/22 LPA didn't observe a reappraisal for R2 after wandering behavior. This poses a potential health and safety risk to resident.

Safety measures to address behaviors such as wandering, aggressive behavior...This requirement not met as evidence by: On 3/22/22 LPA observed that R2 exited the facility unassited by staff, there was no staff monitoring exits. This poses a potential health and safety risk to residents.

The licensee shall have an auditory device or other staff alert feature to monitor exits... This requirement not met as evidenced by: On 3/22/22 and 5/4/22 LPA observed backdoor was opened and auditory device was inoperable. This poses immediate risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidence by: Based on observation, interviews, and record reviews (R1) was not accorded a safe environment when staff allowed a child to roam unattended/unsupervised. This violation poses a potential health and safety risk to residents in care.

Building and Grounds (c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.This requirement is not met as evidence by: LPA observed a mat in disrepair in front of the glass doors that lead out to the garden.

Maintenance and operationFaucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate...not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).This requirement is not met as evidence by On 3/8/2022 LPA CIfuentes noted hot water temperature to be 144F. On 3/11/2022, water in four rooms was 130.2F and 135.9F. This is an immediate health and safety risk to the residents in care.

Personal RIghts of Residents All FacilitiesTo be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.This requirement was not met as evidenced by: Based on LPA/RA Cifuentes on 10/19/21 observations and interviews, the facility did not insure residents in the facility were free from intimidation or abuse. This poses a potential Health & Safety risk to residents in care.

87465Incidental Medical and Dental Care(a)(2)(a)...(2)The licensee shall provide assistance in meeting necessary medical and dental needs...y which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.This requirement is not met as evidenced by: Based on interviews, and record review, on 1/20/22, LPA was informed, per interviews, by 4 of 6 residents and 3 of 6 staff persons, that the facility does not pay for resident medical transportation trips as stated in admission agreement, which posed a potential health risk to residents in care.

87113 Posting of License.The license shall be posted in a prominent location in the licensed facility accessible to public view. On 1/20/22 at 1:10pm, LPA observed that the Gardena Residential Center license was not posted in the lobby for public view.

Personnel Requirements - GeneralStaff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: During complaint investigation, LPA Cifuentes did not observe current CPR/First aid training for Staff 1 - Staff 4. This posses a potential health and safety risk for clients in care

Personal RIghts of Residents All FacilitiesTo be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.This requirement was not met as evidenced by: Based on LPA's observations and interviews facility did not insure residents in facility were free from intimidation or abuse. This poses a potential Health and Safety risk to residents in care

Personnel Requirements - GeneralFacility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by: Based on interviews, observation, and record review, on 8/5/2021, LPA that facility does not have sufficient staff which poses a potential health risk to residents in care.

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on interviews, observation, and record review, on 8/5/2021, LPA observed that R1, a fall risk, did not have a fall prevention plan which poses a potential health risk to residents in care.