197607682-6-24-2020-11-AS-MVAO-BRAQMZ-20200707121821

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 06/22/2020
Date Signed: 06/24/2020 04:37:12 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2020 and conducted by Evaluator Erik Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200612161457

FACILITY NAME:	HAYWORTH TERRACE		FACILITY NUMBER:	197607682
ADMINISTRATOR:	HELEN PAK		FACILITY TYPE:	740
ADDRESS:	325 N. HAYWORTH AVENUE		TELEPHONE:	(323) 655-3101
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	111	CENSUS: 76	DATE:	06/22/2020
		UNANNOUNCED	TIME BEGAN:	03:11 PM
MET WITH:	Helen Pak, Administrator		TIME COMPLETED:	04:12 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff do not keep the facility clean
Facility staff are not properly supervising residents

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this date, Licensing Program Analyst (LPA) Erik Brown conducted an unannounced complaint tele-visit to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Helen Pak, the facility Administrator.

During the initial telephone visit on 6/16/2020, LPA discussed the allegation with Administrator Helen Pak. LPA virtually toured the facility via FaceTime. LPA Brown conducted telephone interviews with Staff #1-3 (S1-S3). LPA also requested copies of the facility cleaning schedule.

During the investigation on 6/19/2020, LPA interviewed Residents #1-7 (R1-7) along with Staff #4 (S4) regarding the complaint allegations.

Report continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2020

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-20200612161457

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
MONTEREY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 197607682
	VISIT DATE: 06/22/2020

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

The investigation revealed the following for allegations:

(Facility staff do not keep the facility clean)
(Facility staff are not properly supervising residents)

Based on interviews with Staff #1-4 (S1-S4), facility staff generally stated that the facility is kept clean and maintained throughout the day. Facility staff also stated that they have enough staff to properly supervise residents and that residents are not seen fighting and arguing with each other.

Based on interviews with Residents#1-7 (R1-R7), residents generally stated that the facility is not dirty and is cleaned often. Residents also generally stated that they have not seen residents arguing or fighting with one another.

Based on LPA Brown’s observations, the records that were reviewed (facility cleaning schedule), and the interviews that were conducted, 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 allegations are unsubstantiated.

A telephonic exit interview was conducted with Administrator Helen Pak, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2