197607682-9-16-2020-11-AS-EMAZ-BTRTTX-20200924150126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 09/04/2020
Date Signed: 09/16/2020 10:41:27 AM

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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2020 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200713114811

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: 78	DATE:	09/04/2020
		UNANNOUNCED	TIME BEGAN:	01:14 PM
MET WITH:	Julie Arriola & Helen Pak		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff move client to another facility without authorization.
Facility staff withheld resident's P&I money.
Facility staff did not safeguard resident's cash resources.

INVESTIGATION FINDINGS:

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On 09/04/20, Licensing Program Analyst, LPA/Ernand Dabuet initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Julie Arriola /Med-Tech at this facility. Helen Pak/Administrator was not present during the visit, however, Pak was included in the telephone call.

The investigation consisted of the following: interviews with staff and residents, a plant inspection of the facility, a copy of a current staff/resident roster, facility's financial records, (R-1's) pre-placement appraisal, physician’s report, emergency contact information, medications, admissions agreement other pertinent documents relevant to the investigation were reviewed.

Evaluation Report continues on LIC-9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020

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 3

Control Number 11-AS-20200713114811

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
MONTERY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 197607682
	VISIT DATE: 09/04/2020

NARRATIVE

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Allegation: Facility staff move client to another facility without authorization.

It is alleged the facility moved Resident #1 (R-1) to another facility without authorization. On 03/15/18, (R-1) self-admitted himself at this facility and did not have an appointed conservator or Power of Attorney. During interviews with staff (S1-S3) it was revealed that (R-1) had applied for The Assisted Living Waiver Program (ALW). assisted by Archangel Home Health, Inc with the relocation to find a facility that accepted (ALW) program. (R-1) later settled on The Arcadia Retirement Village and moved in on 04/30/20. The complainant states that (R-1) was manipulated to move in Arcadia Retirement Village by the Administrator. The Administrator denies this claim and states that no one influence or controlled (R-1) into moving to another facility. The administrator stated that (R-1) was given the option that he could go back and forth between Hayworth and Arcadia facilities until he decided which facility suited him better. An interview with (R-1) states he likes Arcadia Retirement Village and prefers it over Hayworth Terrace. (R-1) states I like it very much and it is better for me. I did not have friends at Hayworth. (R-1) reports that no one forced or manipulated him to move. The Department reviewed (R-1) medical records and it revealed that (R-1's) mental condition was never a concern and is capable of self-care and competent in making sound decisions. Based on the information gather, there is no evidence to corroborate the allegation mentioned above.

Allegation: Facility staff withheld resident's P&I money.
Facility staff did not safeguard resident's cash resources.

It is alleged a facility withheld resident's P&I money and did not safeguard resident's cash resources. The Department interviewed staff (S1-S7) and residents (R1-R8) along with a review of (R-1’s) service records and found there is no evidence to support the allegations mentioned above. The Department reviewed the facility’s Residential Care Admission Agreement with (R-1) it clearly states in the agreement “the facility provides no assistance with or management of any residents’ money”. An interview with (S1-S7) and (R2-R8) was able to validate the facility is not responsible to safeguard residents' cash resources or personal and incidentals (P&I). According to (R-1’s) Physician’s Report he is able to self-care and manage his own cash resources. An interview with (R-1) confirms that the facility did not safeguard his cash resources. The Administrator states the facility does not safeguard resident’s cash resources.

Evaluation Report continues on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200713114811

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
MONTERY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 197607682
	VISIT DATE: 09/04/2020

NARRATIVE

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The complainant claims the (R-1’s) cash resources were mishandled and that part of (R-1’s) COVID-19 Stimulus was garnished and used to satisfy a debt owed by (R-1) for defaulted rent payments. The Administrator claims (R-1) was never in default of rent payments and denies having any knowledge of (R-1’s) COVID-19 Stimulus payment. The Administrator denies having access to (R-1’s) personal checking account and claims (R-1) is self-payee on SSI benefits and that (R-1) would make rent payments in cash. An interview with (R-1) revealed that the resident was uncertain about the total amount he paid for rent and in what form of payment was made monthly. Interviews with (R2-R8) all confirmed that the facility does not safeguard or handle any of the resident’s finances and they have not encountered any problems with rent payments or COVID-19 Stimulus checks. The complainant states (S-3) was an integral link for communications with the administrator regarding a debt owed by (R-1) to the facility. An interview with (S-3) denies having any communications with the complainant regarding finances. The Department reviewed the facility’s bank statements and rent receivable log from the period January 2020 through July 2020 and did not find any discrepancies, errors, or omissions. Based on the Department’s observation, interviews, and a review of service/financial records which were conducted, the Department found there is no evidence to support the allegations mentioned above.

Based on information gathered, the Department did not find sufficient evidence to support the allegations: “Facility staff move client to another facility without authorization”, “Facility staff withheld resident's P&I money", and "Facility staff did not safeguard resident's cash resources".

Although the allegations may have happened or are valid, there is not enough preponderance of evidence to prove the alleged allegations are valid did or did not occur. Therefore, the allegations are "unsubstantiated.”

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

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020

LIC9099 (FAS) - (06/04)

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